Provider Demographics
NPI:1538230859
Name:MARK G. KIMBLE, D.C. PA
Entity type:Organization
Organization Name:MARK G. KIMBLE, D.C. PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:KIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-327-6155
Mailing Address - Street 1:518 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3384
Mailing Address - Country:US
Mailing Address - Phone:803-327-6155
Mailing Address - Fax:803-327-5062
Practice Address - Street 1:518 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3384
Practice Address - Country:US
Practice Address - Phone:803-327-6155
Practice Address - Fax:803-327-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH122Medicaid
SCU657330281Medicare PIN
SCU657330281Medicare UPIN