Healthcare Provider Details

I. General information

NPI: 1639441520
Provider Name (Legal Business Name): CINAMON K KIMBROUGH LAC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10304 N HAYDEN RD STE 100
SCOTTSDALE AZ
85258-1218
US

IV. Provider business mailing address

10002 N 7TH ST APT 1106
PHOENIX AZ
85020-1755
US

V. Phone/Fax

Practice location:
  • Phone: 815-701-1259
  • Fax:
Mailing address:
  • Phone: 815-701-1259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number010012
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-20576
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: