Provider Demographics
NPI:1407990625
Name:SPERRY, KIM HARRISON (DC)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:HARRISON
Last Name:SPERRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CIRCLE WAY ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5200
Mailing Address - Country:US
Mailing Address - Phone:979-297-0002
Mailing Address - Fax:979-297-0002
Practice Address - Street 1:104 CIRCLE WAY ST
Practice Address - Street 2:SUITE D
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5200
Practice Address - Country:US
Practice Address - Phone:979-297-0002
Practice Address - Fax:979-297-0002
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC2864111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760047771OtherTAX IDENTIFICATION NUMBER
TX760047771OtherTAX IDENTIFICATION NUMBER
TX601183Medicare ID - Type Unspecified