Healthcare Provider Details

I. General information

NPI: 1902174345
Provider Name (Legal Business Name): DERRICK E KIMBLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2903 GALAHAD WAY
AUGUSTA GA
30909-9147
US

IV. Provider business mailing address

2903 GALAHAD WAY
AUGUSTA GA
30909-9147
US

V. Phone/Fax

Practice location:
  • Phone: 706-495-2351
  • Fax:
Mailing address:
  • Phone: 706-495-2351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberRN107823
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005188
License Number StateGA

VIII. Authorized Official

Name: DERRICK E KIMBLE
Title or Position: CEO
Credential: MED
Phone: 706-495-2351