Healthcare Provider Details

I. General information

NPI: 1407856826
Provider Name (Legal Business Name): KIMBERLY S GOLD LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 S MAIN ST
BLACKSTONE VA
23824-2614
US

IV. Provider business mailing address

PO BOX 238
BLACKSTONE VA
23824-0238
US

V. Phone/Fax

Practice location:
  • Phone: 434-292-4167
  • Fax: 434-292-7554
Mailing address:
  • Phone: 434-292-4167
  • Fax: 434-292-7554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305002622
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: