Healthcare Provider Details

I. General information

NPI: 1477733897
Provider Name (Legal Business Name): KIM CARLSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 RALEIGH RD
LAS CRUCES NM
88005-7717
US

IV. Provider business mailing address

916 RALEIGH RD
LAS CRUCES NM
88005-7717
US

V. Phone/Fax

Practice location:
  • Phone: 505-526-9254
  • Fax:
Mailing address:
  • Phone: 505-526-9254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number706
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: