Healthcare Provider Details

I. General information

NPI: 1699781435
Provider Name (Legal Business Name): PHILIP LAWRENCE IMBODY KINESIOTHERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 MEMORIAL BLVD
KERRVILLE TX
78028-5768
US

IV. Provider business mailing address

2162 FOREST TRAIL DR
BANDERA TX
78003-3727
US

V. Phone/Fax

Practice location:
  • Phone: 830-896-2020
  • Fax:
Mailing address:
  • Phone: 830-796-3601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: