Healthcare Provider Details

I. General information

NPI: 1275598468
Provider Name (Legal Business Name): WENTZELLE KIM KITCHENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SPARTA RD SUITE F
SANDERSVILLE GA
31082-1371
US

IV. Provider business mailing address

501 SPARTA RD SUITE F
SANDERSVILLE GA
31082-1371
US

V. Phone/Fax

Practice location:
  • Phone: 478-552-0001
  • Fax: 478-552-0048
Mailing address:
  • Phone: 478-552-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number038277
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number038277
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: