Healthcare Provider Details

I. General information

NPI: 1265916720
Provider Name (Legal Business Name): MRS. KIMBERLY MCKEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 E RALPH HALL PKWY STE 21
ROCKWALL TX
75032-6877
US

IV. Provider business mailing address

1601 WALNUT ST
COMMERCE TX
75428-3347
US

V. Phone/Fax

Practice location:
  • Phone: 847-337-7087
  • Fax:
Mailing address:
  • Phone: 847-337-7087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1767974
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: