Provider Demographics
NPI:1790133007
Name:NGUYEN, KIM THAO THI
Entity Type:Individual
Prefix:
First Name:KIM THAO
Middle Name:THI
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N 14TH ST
Mailing Address - Street 2:SUITE 550
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112
Mailing Address - Country:US
Mailing Address - Phone:408-294-3922
Mailing Address - Fax:408-294-4657
Practice Address - Street 1:25 N 14TH ST
Practice Address - Street 2:SUITE 550
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:408-294-3922
Practice Address - Fax:408-294-4657
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA945965220Medicare PIN