Healthcare Provider Details

I. General information

NPI: 1396519302
Provider Name (Legal Business Name): CHARLES MAINA KIMANI RN BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4393 INDIGO ST NE
SALEM OR
97305-2137
US

IV. Provider business mailing address

4393 INDIGO ST NE
SALEM OR
97305-2137
US

V. Phone/Fax

Practice location:
  • Phone: 503-393-0590
  • Fax: 503-966-3990
Mailing address:
  • Phone: 503-393-0590
  • Fax: 503-966-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number202103475RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: