Provider Demographics
NPI:1598779241
Name:STEPHEN W KIMBALL DC PC
Entity Type:Organization
Organization Name:STEPHEN W KIMBALL DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-345-0070
Mailing Address - Street 1:203 E HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1125
Mailing Address - Country:US
Mailing Address - Phone:989-345-0070
Mailing Address - Fax:989-345-6022
Practice Address - Street 1:203 E HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1125
Practice Address - Country:US
Practice Address - Phone:989-345-0070
Practice Address - Fax:989-345-6022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
950F510060OtherBCBSM
T33482Medicare UPIN
0M77500Medicare ID - Type Unspecified