Basic Information
| Provider Information | |||||||||
| NPI: | 1023441953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBLE | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3216 WATERBRIDGE CT | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347449241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078928823 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10395 NARCOOSSEE RD | ||||||||
| Address2: | STE E | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328326939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077303244 | ||||||||
| FaxNumber: | 4077303246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA 24215 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.