1104975846 NPI number — KIMBERLY NICOLE COLON PHYSICAL THERAPIST

Table of content: KIMBERLY NICOLE COLON PHYSICAL THERAPIST (NPI 1104975846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104975846 NPI number — KIMBERLY NICOLE COLON PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLON
Provider First Name:
KIMBERLY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
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:
1104975846
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4560 SE INTERNATIONAL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-206-5140
Provider Business Mailing Address Fax Number:
971-206-5209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 PARKSIDE DR STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94596-3532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-784-3322
Provider Business Practice Location Address Fax Number:
971-206-5209
Provider Enumeration Date:
01/10/2007

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 , with the licence number:  28805 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com