Provider Demographics
NPI:1376997221
Name:KIMBERLEY I. SHINE MD INC.
Entity Type:Organization
Organization Name:KIMBERLEY I. SHINE MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:I
Authorized Official - Last Name:SHINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-222-8636
Mailing Address - Street 1:65 N 1ST AVE
Mailing Address - Street 2:SUITE 202C
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3207
Mailing Address - Country:US
Mailing Address - Phone:626-222-8636
Mailing Address - Fax:626-462-0974
Practice Address - Street 1:65 N 1ST AVE
Practice Address - Street 2:SUITE 202C
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3207
Practice Address - Country:US
Practice Address - Phone:626-222-8636
Practice Address - Fax:626-462-0974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty