Healthcare Provider Details

I. General information

NPI: 1922698521
Provider Name (Legal Business Name): JOSHUA KIMBLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24705 SPRING BRIAR LN SW
WESTERNPORT MD
21562-2239
US

IV. Provider business mailing address

24705 SPRING BRIAR LN SW
WESTERNPORT MD
21562-2239
US

V. Phone/Fax

Practice location:
  • Phone: 304-636-9396
  • Fax:
Mailing address:
  • Phone: 304-636-9396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: