Provider Demographics
NPI:1326582248
Name:BIG KNIFE, KIM (LAC-E)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BIG KNIFE
Suffix:
Gender:F
Credentials:LAC-E
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 CLINIC RD N
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-8849
Mailing Address - Country:US
Mailing Address - Phone:406-395-4818
Mailing Address - Fax:406-395-4861
Practice Address - Street 1:96 CLINIC RD N
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-8849
Practice Address - Country:US
Practice Address - Phone:406-395-4818
Practice Address - Fax:406-395-4861
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLA-LIC-18786390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program