Healthcare Provider Details

I. General information

NPI: 1417618141
Provider Name (Legal Business Name): KIMBERLY REDITO CAL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1586 BLOOMINGDALE AVE
VALRICO FL
33596-6101
US

IV. Provider business mailing address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0915
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-9700
  • Fax:
Mailing address:
  • Phone: 813-978-9700
  • Fax: 813-558-6054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA29089
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: