MEDICARE: DOMINIC BRUCE KIMERY

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	225700000X	Massage Therapist	2022036755	MO

General Provider Information

NPI Number	:	1902674047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC BRUCE KIMERY

Provider Business Mailing Address
First Line	:	1801 W NORTON RD STE 202
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-5367
Country	:	US
Telephone Number	:	417-416-8919
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 W NORTON RD STE 202
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-5367
Country	:	US
Telephone Number	:	417-416-8919
Fax Number	:

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

Provider Enumeration Date	:	12/18/2023
Last Update Date	:	12/18/2023

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