Healthcare Provider Details

I. General information

NPI: 1487459079
Provider Name (Legal Business Name): WALLACE KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3275 E PLATTE AVE STE D2
COLORADO SPRINGS CO
80909-6444
US

IV. Provider business mailing address

3275 E PLATTE AVE STE D2
COLORADO SPRINGS CO
80909-6444
US

V. Phone/Fax

Practice location:
  • Phone: 719-694-8855
  • Fax:
Mailing address:
  • Phone: 719-694-8855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: