Provider Demographics
NPI:1588352306
Name:FLACK, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 QUAIL RUN DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28150-9001
Mailing Address - Country:US
Mailing Address - Phone:704-751-6215
Mailing Address - Fax:
Practice Address - Street 1:1804 QUAIL RUN DR
Practice Address - Street 2:
Practice Address - City:KINGSTOWN
Practice Address - State:NC
Practice Address - Zip Code:28150-9001
Practice Address - Country:US
Practice Address - Phone:704-751-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5341038343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)