Provider Demographics
NPI:1720520521
Name:WALLENCHECK, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WALLENCHECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11476 LARKIN RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:CA
Mailing Address - Zip Code:95953-9640
Mailing Address - Country:US
Mailing Address - Phone:530-813-0991
Mailing Address - Fax:530-695-1764
Practice Address - Street 1:1650 SIERRA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-8986
Practice Address - Country:US
Practice Address - Phone:530-671-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist