1790858199 NPI number — MISS KIMBERLY M SERRA PT, DPT, MTC, CSCS

Table of content: MISS KIMBERLY M SERRA PT, DPT, MTC, CSCS (NPI 1790858199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790858199 NPI number — MISS KIMBERLY M SERRA PT, DPT, MTC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERRA
Provider First Name:
KIMBERLY
Provider Middle Name:
M
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, MTC, CSCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790858199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 BAY SPRING AVE
Provider Second Line Business Mailing Address:
UNIT A2
Provider Business Mailing Address City Name:
BARRINGTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02806-1385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-289-2553
Provider Business Mailing Address Fax Number:
401-289-2883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 BAY SPRING AVE
Provider Second Line Business Practice Location Address:
A2
Provider Business Practice Location Address City Name:
BARRINGTON
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02806-1384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-289-2553
Provider Business Practice Location Address Fax Number:
401-289-2883
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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