MEDICARE: MR. MELVIN G KIMBLE

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	172A00000X	Driver	42700532

General Provider Information

NPI Number	:	1417620345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MELVIN G KIMBLE

Provider Business Mailing Address
First Line	:	120 ZACK CIR
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-9617
Country	:	US
Telephone Number	:	252-207-1166
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 ZACK CIR
Second Line	:
City	:	ELIZABETH CTY
State	:	NC
Zip	:	27909-9617
Country	:	US
Telephone Number	:	252-207-1166
Fax Number	:

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

Provider Enumeration Date	:	07/27/2021
Last Update Date	:	03/30/2022

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