Provider Demographics
NPI:1689781031
Name:OSBORNE, KIM (MHS PT)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:MHS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-5227
Mailing Address - Fax:575-396-7193
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-5227
Practice Address - Fax:575-396-7193
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2387OtherHCH ID
NMNM00Q024OtherBLUE CROSS ID
NMPROVP15381OtherMOLINA ID