Provider Demographics
NPI:1831324441
Name:KIMBROUGH AMBLATORY CARE CENTER
Entity Type:Organization
Organization Name:KIMBROUGH AMBLATORY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:STACY-BONOT
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:301-677-8670
Mailing Address - Street 1:2480 LLEWELLYN AVE STE 5800
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE STE 5800
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5129
Practice Address - Country:US
Practice Address - Phone:301-677-8670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR168995261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care