Provider Demographics
NPI:1568808947
Name:KIMURA, DANIEL GLEN
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:GLEN
Last Name:KIMURA
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 1:2201 AMBASSADOR RD NE APT 206
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2749
Mailing Address - Country:US
Mailing Address - Phone:505-489-4858
Mailing Address - Fax:
Practice Address - Street 1:2201 AMBASSADOR RD NE APT 206
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2749
Practice Address - Country:US
Practice Address - Phone:505-489-4858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7493171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor