=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821755174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMO CECIL COLLINS LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2021
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 727 SE CASS AVE STE 308
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470-4954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-530-3016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 HARVEST LN
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97471-9269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-530-3016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 28013
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------