Healthcare Provider Details

I. General information

NPI: 1316004781
Provider Name (Legal Business Name): WALTER DALE KIMBERLIN JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 BROADWAY
PORT EWEN NY
12466-5501
US

IV. Provider business mailing address

PO BOX 927
PORT EWEN NY
12466-0927
US

V. Phone/Fax

Practice location:
  • Phone: 845-331-8810
  • Fax: 845-331-8810
Mailing address:
  • Phone: 845-331-8810
  • Fax: 845-331-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX009684
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: