1043988116 NPI number — TANNER C KIMBLE CST/CSFA

Table of content: TANNER C KIMBLE CST/CSFA (NPI 1043988116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043988116 NPI number — TANNER C KIMBLE CST/CSFA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMBLE
Provider First Name:
TANNER
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CST/CSFA
Provider Gender Code:
M

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:
1043988116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 LACASA LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83301-5663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-410-0569
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 HIGHWAY 61 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICKSBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39183-8211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-883-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2021

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: 246ZC0007X , with the licence number:  188016 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 188016 . This is a "THE NATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com