Healthcare Provider Details

I. General information

NPI: 1487866083
Provider Name (Legal Business Name): KIM MCMANUS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 RENAISSANCE WOODS CT
XENIA OH
45385-8703
US

IV. Provider business mailing address

25 RENAISSANCE WOODS CT
XENIA OH
45385-8703
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-3463
  • Fax: 937-347-2911
Mailing address:
  • Phone: 937-376-3463
  • Fax: 937-347-2911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001847
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: