Provider Demographics
NPI:1063710143
Name:BALDWIN, KIM JENON
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:JENON
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1022
Mailing Address - Street 2:201 W 3RD ST
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-1022
Mailing Address - Country:US
Mailing Address - Phone:970-379-6418
Mailing Address - Fax:970-625-5505
Practice Address - Street 1:201 W 3RD ST
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-2245
Practice Address - Country:US
Practice Address - Phone:970-379-6418
Practice Address - Fax:970-625-5505
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT7258225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist