Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4154 | OK |
N | 111NR0400X | Rehabilitation Chiropractor | 4154 | OK |
N | 111NS0005X | Chiropractic Sports Physician | 4154 | OK |
N | 111NX0100X | Occupational Health | 4154 | OK |
NPI | 1083025670 |
---|---|
Provider Name | Mr. Mark A. Kimble JR. |
First Address | Yukon, OK 73099 |
Second Address | Yukon, OK 73099 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2014 |
Last Update Date | 07/04/2017 |