Provider Demographics
NPI:1003380726
Name:KIMARI, FESTUS MUGO
Entity Type:Individual
Prefix:MR
First Name:FESTUS
Middle Name:MUGO
Last Name:KIMARI
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 1:16504 W 141ST ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1940
Mailing Address - Country:US
Mailing Address - Phone:913-742-3646
Mailing Address - Fax:913-489-7116
Practice Address - Street 1:16504 W 141ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1940
Practice Address - Country:US
Practice Address - Phone:913-742-3646
Practice Address - Fax:913-489-7116
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK02-55-3358172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201194620AMedicaid