Healthcare Provider Details

I. General information

NPI: 1679606149
Provider Name (Legal Business Name): MS. KIMBERLY LOUISE BUMPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 FROST ST
OXFORD NC
27565-3441
US

IV. Provider business mailing address

115 FROST ST
OXFORD NC
27565-3441
US

V. Phone/Fax

Practice location:
  • Phone: 191-969-3796
  • Fax: 191-969-3696
Mailing address:
  • Phone: 191-969-3796
  • Fax: 191-969-3696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-039-042
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: