Provider Demographics
NPI:1194897827
Name:BLOUNT KIMBALL MEDICAL OPTOMETRY PA
Entity type:Organization
Organization Name:BLOUNT KIMBALL MEDICAL OPTOMETRY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V. PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:B
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:409-899-9999
Mailing Address - Street 1:4105 DOWLEN RD STE B
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6871
Mailing Address - Country:US
Mailing Address - Phone:409-899-9999
Mailing Address - Fax:409-892-6587
Practice Address - Street 1:4105 DOWLEN RD STE B
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6871
Practice Address - Country:US
Practice Address - Phone:409-899-9999
Practice Address - Fax:409-892-6587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4254380001Medicare NSC