Healthcare Provider Details

I. General information

NPI: 1871609727
Provider Name (Legal Business Name): LYNDE HARRISON KIMBALL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 PUTNEY RD
BRATTLEBORO VT
05301-9062
US

IV. Provider business mailing address

PO BOX 8427
BRATTLEBORO VT
05304-8427
US

V. Phone/Fax

Practice location:
  • Phone: 802-254-6900
  • Fax: 802-254-7610
Mailing address:
  • Phone: 802-254-6900
  • Fax: 802-254-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number030-0000113
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: