Healthcare Provider Details

I. General information

NPI: 1376976076
Provider Name (Legal Business Name): KINTA MARIA BLUMENTHAL BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 06/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W MAPLE ST
RAWLINS WY
82301-5447
US

IV. Provider business mailing address

721 W MAPLE ST
RAWLINS WY
82301-5447
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-7156
  • Fax:
Mailing address:
  • Phone: 307-324-7156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: