Provider Demographics
NPI:1790080471
Name:DIEHL, KIM L (MT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:DIEHL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 AGENCY MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:MT
Mailing Address - Zip Code:59526-9455
Mailing Address - Country:US
Mailing Address - Phone:406-353-3100
Mailing Address - Fax:406-353-3108
Practice Address - Street 1:669 AGENCY MAIN ST
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:MT
Practice Address - Zip Code:59526-9455
Practice Address - Country:US
Practice Address - Phone:406-353-3100
Practice Address - Fax:406-353-3108
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI146661247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI146661OtherLICENSE