1992271647 NPI number — WHITNEY RENEE KIMBLE

Table of content: DR. MICHELLE COOPER CANTRELL O.D. (NPI 1407060320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992271647 NPI number — WHITNEY RENEE KIMBLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMBLE
Provider First Name:
WHITNEY
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TARVER
Provider Other First Name:
WHITNEY
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992271647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1098 WORTHINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTERVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28590-7838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-220-9352
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 NASH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27896-1394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-900-7438
Provider Business Practice Location Address Fax Number:
919-900-7576
Provider Enumeration Date:
10/21/2018

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: 101YM0800X , with the licence number:  A12153 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: LCAS-23247 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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