1043346208 NPI number — DR. KIMEL A. LIMON PSYD

Table of content: DR. KIMEL A. LIMON PSYD (NPI 1043346208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043346208 NPI number — DR. KIMEL A. LIMON PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIMON
Provider First Name:
KIMEL
Provider Middle Name:
A.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043346208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16340 LOWER HARBOR RD
Provider Second Line Business Mailing Address:
# 331
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97415-8303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-254-0941
Provider Business Mailing Address Fax Number:
707-812-6106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 H ST
Provider Second Line Business Practice Location Address:
STE 1N
Provider Business Practice Location Address City Name:
CRESCENT CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95531-3736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-254-0941
Provider Business Practice Location Address Fax Number:
707-812-6106
Provider Enumeration Date:
02/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 17613 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSY176130 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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