Provider Demographics
NPI:1144458860
Name:KIMBALL, SAMUEL HEBER (OD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:HEBER
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 N PINE ST
Mailing Address - Street 2:STE 3
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3543
Mailing Address - Country:US
Mailing Address - Phone:541-963-3788
Mailing Address - Fax:541-963-3091
Practice Address - Street 1:1502 N PINE ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3543
Practice Address - Country:US
Practice Address - Phone:541-963-3788
Practice Address - Fax:541-963-3091
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3311AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist