Provider Demographics
NPI:1275520884
Name:KIM-SHOLEY, HELEN D (O D)
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:D
Last Name:KIM-SHOLEY
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:HELEN
Other - Middle Name:D
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:O D
Mailing Address - Street 1:544 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-6346
Mailing Address - Country:US
Mailing Address - Phone:307-382-3937
Mailing Address - Fax:307-382-2918
Practice Address - Street 1:544 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6346
Practice Address - Country:US
Practice Address - Phone:307-382-3937
Practice Address - Fax:307-382-2918
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY218T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY10981100Medicaid
WY10981100Medicaid
WY307684Medicare PIN
WYU50033Medicare UPIN
WY4978190001Medicare NSC