Provider Demographics
NPI:1821492125
Name:KIM SALLOUX LAC
Entity Type:Organization
Organization Name:KIM SALLOUX LAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:GRETHER
Authorized Official - Last Name:SALLOUX
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:415-845-7288
Mailing Address - Street 1:214 S 7TH
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047
Mailing Address - Country:US
Mailing Address - Phone:415-846-7288
Mailing Address - Fax:
Practice Address - Street 1:109 W CALLENDER SUITE 2E
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047
Practice Address - Country:US
Practice Address - Phone:415-846-7288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT32222305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization