Healthcare Provider Details

I. General information

NPI: 1942277603
Provider Name (Legal Business Name): KIMBERLY JOANNE SHORE RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 CORNELIA RD
ANDERSON SC
29621-3317
US

IV. Provider business mailing address

227 S PENDLETON ST STE B
EASLEY SC
29640-3084
US

V. Phone/Fax

Practice location:
  • Phone: 864-225-8321
  • Fax:
Mailing address:
  • Phone: 864-855-7030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberSC4041
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4041
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: