Provider Demographics
NPI:1336933613
Name:EDGAR, KIM D
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:D
Last Name:EDGAR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BELLEVUE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2736
Mailing Address - Country:US
Mailing Address - Phone:860-207-4477
Mailing Address - Fax:
Practice Address - Street 1:38 ELDREDGE MILLS RD
Practice Address - Street 2:
Practice Address - City:WILLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06279-1301
Practice Address - Country:US
Practice Address - Phone:860-487-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider