Provider Demographics
NPI:1578922019
Name:KIMBLE-MARVEL, MYRON
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:
Last Name:KIMBLE-MARVEL
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 1:411 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4203
Mailing Address - Country:US
Mailing Address - Phone:410-274-7038
Mailing Address - Fax:
Practice Address - Street 1:411 ARBOR DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4203
Practice Address - Country:US
Practice Address - Phone:410-274-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05303225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist