Provider Demographics
NPI:1013019850
Name:KIMBLE, TIMOTHY JOSEPH (DC, FACO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:DC, FACO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE STE G
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-674-8711
Mailing Address - Fax:951-674-1156
Practice Address - Street 1:600 CENTRAL AVE STE G
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2740
Practice Address - Country:US
Practice Address - Phone:951-674-8711
Practice Address - Fax:951-674-1156
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15809111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0158090Medicare ID - Type Unspecified