Provider Demographics
NPI:1740828276
Name:KIMBALL, OTIS ARTHUR
Entity type:Individual
Prefix:
First Name:OTIS
Middle Name:ARTHUR
Last Name:KIMBALL
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 1:325 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-4628
Mailing Address - Country:US
Mailing Address - Phone:918-273-7344
Mailing Address - Fax:
Practice Address - Street 1:325 S ASH ST
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-4628
Practice Address - Country:US
Practice Address - Phone:918-273-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator