1194312512 NPI number — KIM GETHERS IO WAIVER PROVIDER

Table of content: KIM GETHERS IO WAIVER PROVIDER (NPI 1194312512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194312512 NPI number — KIM GETHERS IO WAIVER PROVIDER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GETHERS
Provider First Name:
KIM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
IO WAIVER PROVIDER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GETHERS
Provider Other First Name:
KIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
IO WAIVER PROVIDER
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194312512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3936 E 154TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44128-1118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-640-0308
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3936 E 154TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44128-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-640-0308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/31/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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