Provider Demographics
NPI:1548633399
Name:KIM'S WELLNESS CENTER
Entity type:Organization
Organization Name:KIM'S WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDRINI-SENN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:917-456-6385
Mailing Address - Street 1:1011 NE HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:917-456-6385
Mailing Address - Fax:844-401-8624
Practice Address - Street 1:917 SW OAK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:917-456-6385
Practice Address - Fax:844-401-8624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR165166261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center