Basic Information
| Provider Information | |||||||||
| NPI: | 1962172338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIMBLE | ||||||||
| FirstName: | CELESTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9303 GILCREASE AVE UNIT 1141 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891496110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083744451 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1409 E LAKE MEAD BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890307120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026497711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2021 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A-1179 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0000000000 | 05 | NV | MEDICAID |