Basic Information
| Provider Information | |||||||||
| NPI: | 1780213611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | KIMMYBEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3240 FORT WORTH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784112421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6137611924 | ||||||||
| FaxNumber: | 3617613689 | ||||||||
| Practice Location | |||||||||
| Address1: | 7101 S PADRE ISLAND DR | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784124913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617611000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2020 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.