Provider Demographics
NPI:1205918448
Name:KIM, CARLY (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S. VILLA OAKS DR.
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77382
Mailing Address - Country:US
Mailing Address - Phone:281-323-0098
Mailing Address - Fax:
Practice Address - Street 1:605 HOLDERRIETH BLVD
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-6445
Practice Address - Country:US
Practice Address - Phone:281-401-7732
Practice Address - Fax:281-357-2253
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80217133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered