MEDICARE: DR. WALTER DALE KIMBERLIN JR. D.C.

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	111N00000X	Chiropractor	X009684	NY

General Provider Information

NPI Number	:	1316004781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER DALE KIMBERLIN JR. D.C.

Provider Business Mailing Address
First Line	:	PO BOX 927
Second Line	:
City	:	PORT EWEN
State	:	NY
Zip	:	12466-0927
Country	:	US
Telephone Number	:	845-331-8810
Fax Number	:	845-331-8810

Provider Business Practice Location Address
First Line	:	327 BROADWAY
Second Line	:
City	:	PORT EWEN
State	:	NY
Zip	:	12466-5501
Country	:	US
Telephone Number	:	845-331-8810
Fax Number	:	845-331-8810

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	08/03/2012

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