Healthcare Provider Details

I. General information

NPI: 1396786513
Provider Name (Legal Business Name): VIKKI KOLB LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VIKKI KOLB LMT

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 FAIRPORT NINE MILE PT RD SUITE 403
PENFIELD NY
14526-1749
US

IV. Provider business mailing address

2060 FAIRPORT NINE MILE PT RD SUITE 403
PENFIELD NY
14526-1749
US

V. Phone/Fax

Practice location:
  • Phone: 585-261-8105
  • Fax:
Mailing address:
  • Phone: 585-261-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number011919
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: