Provider Demographics
NPI:1720275357
Name:KIM P LARK DO PC
Entity Type:Organization
Organization Name:KIM P LARK DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTI
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:YERBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-234-9964
Mailing Address - Street 1:2402 W PIERCE ST
Mailing Address - Street 2:STE 4A
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3537
Mailing Address - Country:US
Mailing Address - Phone:505-234-9964
Mailing Address - Fax:505-234-9962
Practice Address - Street 1:2402 W PIERCE ST
Practice Address - Street 2:STE 4A
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3537
Practice Address - Country:US
Practice Address - Phone:505-234-9964
Practice Address - Fax:505-234-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA110698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00T9592Medicaid
NMNM004378OtherBCBS