Provider Demographics
NPI:1114985322
Name:KIMBAL, JIM R (ATC, LAT, LMT, CSCS)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:R
Last Name:KIMBAL
Suffix:
Gender:M
Credentials:ATC, LAT, LMT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74293
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-4293
Mailing Address - Country:US
Mailing Address - Phone:907-479-2526
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES STREET
Practice Address - Street 2:FMH REHAB DEPARTMENT
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-458-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10650493-48102255A2300X
IL227005348225700000X
AK117476225700000X
AK1245602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist