Provider Demographics
NPI:1316004781
Name:KIMBERLIN, WALTER DALE JR (DC)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:DALE
Last Name:KIMBERLIN
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:
Mailing Address - City:PORT EWEN
Mailing Address - State:NY
Mailing Address - Zip Code:12466-0927
Mailing Address - Country:US
Mailing Address - Phone:845-331-8810
Mailing Address - Fax:845-331-8810
Practice Address - Street 1:327 BROADWAY
Practice Address - Street 2:
Practice Address - City:PORT EWEN
Practice Address - State:NY
Practice Address - Zip Code:12466-5501
Practice Address - Country:US
Practice Address - Phone:845-331-8810
Practice Address - Fax:845-331-8810
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009684111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU79439Medicare UPIN