Provider Demographics
NPI:1821755174
Name:COLLINS, KIMO CECIL (LMT)
Entity Type:Individual
Prefix:
First Name:KIMO
Middle Name:CECIL
Last Name:COLLINS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13365 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-6422
Mailing Address - Country:US
Mailing Address - Phone:541-530-3016
Mailing Address - Fax:
Practice Address - Street 1:13365 HAWTHORNE DR
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77318-6422
Practice Address - Country:US
Practice Address - Phone:541-530-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT135935225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist