Healthcare Provider Details

I. General information

NPI: 1689975104
Provider Name (Legal Business Name): TIM J. KIRK RDCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 E PERSHING BLVD
CHEYENNE WY
82001-5356
US

IV. Provider business mailing address

2360 E PERSHING BLVD
CHEYENNE WY
82001-5356
US

V. Phone/Fax

Practice location:
  • Phone: 307-778-7550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246W00000X
TaxonomyCardiology Technician
License Number18111
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: