Provider Demographics
NPI:1417620345
Name:KIMBLE, MELVIN G
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:G
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ZACK CIR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9617
Mailing Address - Country:US
Mailing Address - Phone:252-207-1166
Mailing Address - Fax:
Practice Address - Street 1:120 ZACK CIR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CTY
Practice Address - State:NC
Practice Address - Zip Code:27909-9617
Practice Address - Country:US
Practice Address - Phone:252-207-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
42700532172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver