1497380604 NPI number — MOOD BY KIM

Table of content: (NPI 1497380604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497380604 NPI number — MOOD BY KIM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOOD BY KIM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KIMBERLY COCHRAN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497380604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8194 W DEER VALLEY RD STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85382-2127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-777-7551
Provider Business Mailing Address Fax Number:
623-666-6612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7901 4TH ST N STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33702-4399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-777-7551
Provider Business Practice Location Address Fax Number:
623-666-6612
Provider Enumeration Date:
03/08/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COCHRAN
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
623-777-7551

Provider Taxonomy Codes

  • Taxonomy code: 2084A0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2156425 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06543815 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 993686 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".