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General NPI Number Information
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NPI Number | 1952610503
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Entity Type | Individual
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Provider Name | BRANDON KIMBALL
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Gender | Male
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Dates
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Enumeration Date | 09/30/2010
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Last Update Date | 08/11/2020
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Provider Practice Location Address
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Address Line | 2409 S RURAL RD STE D
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City | TEMPE
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State | AZ
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Zip | 85282-2447
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Country | US
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Telephone | 480-966-1635
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Fax |
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Provider Business Mailing Address
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Address Line | 1173 LAKE PARKE DR
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City | SAINT JOHNS
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State | FL
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Zip | 32259-3025
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Country | US
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Telephone | 904-254-8447
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA48778
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT-25350
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License Number State | AZ
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