Healthcare Provider Details

I. General information

NPI: 1750756177
Provider Name (Legal Business Name): KIMBERLY ZOLLER ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 BROADWAY CPO #288
SAN ANTONIO TX
78209
US

IV. Provider business mailing address

14811 HUEBNER RD APT 1207
SAN ANTONIO TX
78231-1741
US

V. Phone/Fax

Practice location:
  • Phone: 210-829-3826
  • Fax:
Mailing address:
  • Phone: 432-638-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5335
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: