Provider Demographics
NPI:1396768164
Name:KIMBRELL, JOHN GRAY (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GRAY
Last Name:KIMBRELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4826 CHICAGO AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1001
Mailing Address - Country:US
Mailing Address - Phone:612-824-4788
Mailing Address - Fax:612-824-7185
Practice Address - Street 1:4826 CHICAGO AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-1001
Practice Address - Country:US
Practice Address - Phone:612-824-4788
Practice Address - Fax:612-824-7185
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU91150Medicare UPIN