Provider Demographics
NPI:1497390942
Name:KIMBALL, RUSSELL IVAN (LMT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:IVAN
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S MAIN ST STE 450
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4114
Mailing Address - Country:US
Mailing Address - Phone:605-377-5930
Mailing Address - Fax:
Practice Address - Street 1:202 S MAIN ST STE 450
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4114
Practice Address - Country:US
Practice Address - Phone:605-377-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT11625225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist