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General NPI Number Information
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NPI Number | 1063783520
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Entity Type | Organization
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Legal Business Name | KENNETH R GAMBLIN, M.D., P.C.
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Dates
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Enumeration Date | 01/14/2012
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Last Update Date | 02/11/2012
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Provider Practice Location Address
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Address Line | 963 E COLORADO AVE
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City | COLORADO SPRINGS
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State | CO
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Zip | 80903-3776
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Country | US
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Telephone | 719-578-1119
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Fax | 719-578-1487
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Provider Business Mailing Address
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Address Line | 963 E COLORADO AVE
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City | COLORADO SPRINGS
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State | CO
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Zip | 80903-3776
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Country | US
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Telephone | 719-578-1119
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Fax | 719-578-1487
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH R GAMBLIN
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Credential |
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Telephone | 719-578-1119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 17345
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License Number State | CO
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