MEDICARE: KIMBERLY HALL MOSSBURG RD, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1609814805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY HALL MOSSBURG RD, ATC

Provider Business Mailing Address
First Line	:	1118 KILLDEER DR
Second Line	:
City	:	GREENTOWN
State	:	IN
Zip	:	46936-1383
Country	:	US
Telephone Number	:	765-628-0806
Fax Number	:

Provider Business Practice Location Address
First Line	:	1118 KILLDEER DR
Second Line	:
City	:	GREENTOWN
State	:	IN
Zip	:	46936-1383
Country	:	US
Telephone Number	:	765-628-0806
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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