Provider Demographics
NPI:1023189438
Name:KIMBLE, MARK G (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3384
Mailing Address - Country:US
Mailing Address - Phone:803-327-6155
Mailing Address - Fax:803-327-5062
Practice Address - Street 1:518 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3384
Practice Address - Country:US
Practice Address - Phone:803-327-6155
Practice Address - Fax:803-327-5062
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7392163OtherAETNA
SCGCH122Medicaid
SCCH0933Medicaid
SCCH0933Medicaid