Provider Demographics
NPI:1801323167
Name:GENGO, KIM WILLIAMS
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:WILLIAMS
Last Name:GENGO
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 1:8301 W JUDGE PEREZ DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-1656
Mailing Address - Country:US
Mailing Address - Phone:469-343-8286
Mailing Address - Fax:
Practice Address - Street 1:8301 W JUDGE PEREZ DR STE 200
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-1656
Practice Address - Country:US
Practice Address - Phone:469-343-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA82-1535364OtherMAJOR MEDICAL