MEDICARE: ADAM KIMBALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A263029	OTHER	OR	DRIVERS LICENSE

General Provider Information

NPI Number	:	1306294251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADAM KIMBALL

Provider Business Mailing Address
First Line	:	4671 S GARDEN SPRING LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5021
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4671 GARDEN SPRING LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5021
Country	:	US
Telephone Number	:	801-518-0954
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2016
Last Update Date	:	06/01/2016

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Directions to “ ADAM KIMBALL ” Practice Location

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