Basic Information
| Provider Information | |||||||||
| NPI: | 1093854226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TABOR | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1373 OXFORD RD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730309306 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730301749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803693900 | ||||||||
| FaxNumber: | 5803693901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10651 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070019951 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5003 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 018TE | 01 | NC | BLUE CROSS GROUP BILLING NUMBER | OTHER |