Healthcare Provider Details

I. General information

NPI: 1114985322
Provider Name (Legal Business Name): JIM R KIMBAL ATC, LAT, LMT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/28/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES STREET FMH REHAB DEPARTMENT
FAIRBANKS AK
99701
US

IV. Provider business mailing address

PO BOX 74293
FAIRBANKS AK
99707-4293
US

V. Phone/Fax

Practice location:
  • Phone: 907-458-5670
  • Fax:
Mailing address:
  • Phone: 907-479-2526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10650493-4810
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227005348
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number117476
License Number StateAK
# 4
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number124560
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: