Provider Demographics
NPI:1588483168
Name:KIMITA, MARTIN MBUTHIA
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:MBUTHIA
Last Name:KIMITA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15216 SE BEVINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-3354
Mailing Address - Country:US
Mailing Address - Phone:781-534-1079
Mailing Address - Fax:
Practice Address - Street 1:14512 SE FOSTER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-4324
Practice Address - Country:US
Practice Address - Phone:781-534-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility