Healthcare Provider Details

I. General information

NPI: 1437189305
Provider Name (Legal Business Name): EARL S KIMBELL III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 B VETERANS BLVD I-40, EXIT 102
ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5300
  • Fax: 505-552-5828
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number3489
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010023062
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: