Healthcare Provider Details

I. General information

NPI: 1689857328
Provider Name (Legal Business Name): GLENN P KIMBALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 MAIN ST
HAVERHILL MA
01830-2644
US

IV. Provider business mailing address

680 MAIN ST
HAVERHILL MA
01830-2644
US

V. Phone/Fax

Practice location:
  • Phone: 978-374-4258
  • Fax: 978-374-4982
Mailing address:
  • Phone: 978-374-4258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number57624
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1177510001
License Number StateMA

VIII. Authorized Official

Name: GLENN P KIMBALL JR.
Title or Position: OWNER
Credential: M.D
Phone: 978-374-4258