Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | C52184 | CA |
Y | 222Z00000X | Podiatrist | C52184 | CA |
NPI | 1053789602 |
---|---|
Provider Name | Benita Kimball |
First Address | Sacramento, CA 95825-3364 |
Second Address | Sacramento, CA 95825-3364 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2015 |
Last Update Date | 22/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C52184 | BOC (01) | CA |