Healthcare Provider Details

I. General information

NPI: 1174728414
Provider Name (Legal Business Name): KIMBROUGH ACC MILITARY MTF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 GIBNER RD USADC
CARLISLE BARRACKS PA
17013-5003
US

IV. Provider business mailing address

2480 LLEWELLYN AVE CDR USAMEDDAC MCXR-BD STE 5800
FORT MEADE MD
20755-7081
US

V. Phone/Fax

Practice location:
  • Phone: 717-245-4542
  • Fax:
Mailing address:
  • Phone: 301-677-8253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRI KIMBROW
Title or Position: UBO MANAGER
Credential:
Phone: 301-677-8512