Provider Demographics
NPI:1851919617
Name:KIMERA, MARTIN KIKULWE
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:KIKULWE
Last Name:KIMERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 N BRIGANTINE LN
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92867-4058
Mailing Address - Country:US
Mailing Address - Phone:714-603-3606
Mailing Address - Fax:
Practice Address - Street 1:1648 N BRIGANTINE LN
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92867-4058
Practice Address - Country:US
Practice Address - Phone:714-603-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA585036163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse