Healthcare Provider Details

I. General information

NPI: 1265060206
Provider Name (Legal Business Name): MRS. KIMBERLY GLOVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. KIMBERLY STORKS

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E SAHARA AVE STE 215
LAS VEGAS NV
89104
US

IV. Provider business mailing address

925 SIERRA VISTA DR #312
LAS VEGAS NV
89169
US

V. Phone/Fax

Practice location:
  • Phone: 702-237-0288
  • Fax: 725-205-2580
Mailing address:
  • Phone: 612-702-1938
  • Fax: 725-205-2580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number20201730463
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: