Provider Demographics
NPI:1740756691
Name:KIMBALL, LEE
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18717 MILL VILLA RD SPC 126
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95327-9353
Mailing Address - Country:US
Mailing Address - Phone:209-352-1933
Mailing Address - Fax:
Practice Address - Street 1:891 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9713
Practice Address - Country:US
Practice Address - Phone:209-754-6734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator