Basic Information
| Provider Information | |||||||||
| NPI: | 1770572182 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIMAIW MED CNTR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOOPA AMBULANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 WALBERT AVE | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181041852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004732278 | ||||||||
| FaxNumber: | 6104352278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 AIRPORT ROAD | ||||||||
| Address2: | |||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306254842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHASE | ||||||||
| AuthorizedOfficialFirstName: | EMMETT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5306254261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic | 146N00000X | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Basic |
ID Information
| ID | Type | State | Issuer | Description | 804242 | 05 | CA | MEDICAID |