Provider Demographics
NPI:1396571295
Name:KIMBROUGH, TYREL D
Entity type:Individual
Prefix:
First Name:TYREL
Middle Name:D
Last Name:KIMBROUGH
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 1:1001 LAWRENCE RD NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44704-1349
Mailing Address - Country:US
Mailing Address - Phone:330-224-6309
Mailing Address - Fax:
Practice Address - Street 1:1001 LAWRENCE RD NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44704-1349
Practice Address - Country:US
Practice Address - Phone:330-224-6309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide