Provider Demographics
NPI:1053789602
Name:KIMBALL, BENITA (CMF)
Entity type:Individual
Prefix:MS
First Name:BENITA
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:CMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 HOWE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3363
Mailing Address - Country:US
Mailing Address - Phone:916-480-9501
Mailing Address - Fax:510-350-9166
Practice Address - Street 1:1329 HOWE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3363
Practice Address - Country:US
Practice Address - Phone:916-480-9501
Practice Address - Fax:510-350-9166
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52184222Z00000X, 224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC52184OtherBOC
CAC52184OtherBOC