Healthcare Provider Details

I. General information

NPI: 1528495165
Provider Name (Legal Business Name): KIMBERLY USCILOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 EASTGATE MALL
SAN DIEGO CA
92121-1979
US

IV. Provider business mailing address

4445 EASTGATE MALL
SAN DIEGO CA
92121-1979
US

V. Phone/Fax

Practice location:
  • Phone: 858-952-1953
  • Fax:
Mailing address:
  • Phone: 858-952-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number014464
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: