=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396519302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES MAINA KIMANI RN BSN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2023
-----------------------------------------------------
Last Update Date | 10/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4393 INDIGO ST NE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97305-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-393-0590
-----------------------------------------------------
Fax | 503-966-3990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4393 INDIGO ST NE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97305-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-393-0590
-----------------------------------------------------
Fax | 503-966-3990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | 202103475RN
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------