Healthcare Provider Details

I. General information

NPI: 1821100249
Provider Name (Legal Business Name): KIMBERLY NOELLE THOMAS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

IV. Provider business mailing address

3900 YORKTOWNE BLVD APT 1305
PORT ORANGE FL
32129-6011
US

V. Phone/Fax

Practice location:
  • Phone: 386-323-7500
  • Fax:
Mailing address:
  • Phone: 386-682-3328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001818
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: