Healthcare Provider Details

I. General information

NPI: 1720275357
Provider Name (Legal Business Name): KIM P LARK DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 W PIERCE ST STE 4A
CARLSBAD NM
88220-3537
US

IV. Provider business mailing address

2402 W PIERCE ST STE 4A
CARLSBAD NM
88220-3537
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-9964
  • Fax: 505-234-9962
Mailing address:
  • Phone: 505-234-9964
  • Fax: 505-234-9962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA110698
License Number StateNM

VIII. Authorized Official

Name: MS. CHRISTI MICHELLE YERBY
Title or Position: BILLING SPECIALIST
Credential:
Phone: 505-234-9964