Provider Demographics
NPI:1699494690
Name:KIMBALL, KEERA
Entity type:Individual
Prefix:
First Name:KEERA
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEERA
Other - Middle Name:
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4200 W VALHALLA BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-3715
Mailing Address - Country:US
Mailing Address - Phone:712-239-0424
Mailing Address - Fax:
Practice Address - Street 1:100 N KROHN PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-1815
Practice Address - Country:US
Practice Address - Phone:605-331-0588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT11866225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist