Healthcare Provider Details

I. General information

NPI: 1700377967
Provider Name (Legal Business Name): KIM PENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9718 HARVARD ST
BELLFLOWER CA
90706
US

IV. Provider business mailing address

9718 HARVARD ST
BELLFLOWER CA
90706-3635
US

V. Phone/Fax

Practice location:
  • Phone: 562-925-2777
  • Fax:
Mailing address:
  • Phone: 562-925-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR11901214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: