Provider Demographics
NPI:1174879894
Name:RANDAL S. KIMBROUGH
Entity type:Organization
Organization Name:RANDAL S. KIMBROUGH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-751-9899
Mailing Address - Street 1:2702 AMERICAN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6937
Mailing Address - Country:US
Mailing Address - Phone:479-751-9899
Mailing Address - Fax:
Practice Address - Street 1:2702 AMERICAN ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6937
Practice Address - Country:US
Practice Address - Phone:479-751-9899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177728608Medicaid