Healthcare Provider Details

I. General information

NPI: 1184099103
Provider Name (Legal Business Name): KENNY RAY KIMBALL II PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N RACE ST
GLASGOW KY
42141-3473
US

IV. Provider business mailing address

249 LOVERS LN
GLASGOW KY
42141-1000
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-7882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number006743
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: