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General NPI Number Information
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NPI Number | 1356797542
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Entity Type | Organization
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Legal Business Name | KODA PHYSICAL THERAPY AND SPORTS PERFORMANCE
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Dates
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Enumeration Date | 05/06/2016
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Last Update Date | 06/10/2021
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Provider Practice Location Address
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Address Line | 1600 CORPORATE CIR
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City | PETALUMA
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State | CA
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Zip | 94954-6912
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Country | US
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Telephone | 707-981-8604
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Fax | 707-981-8647
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Provider Business Mailing Address
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Address Line | 1600 CORPORATE CIR
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City | PETALUMA
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State | CA
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Zip | 94954-6912
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Country | US
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Telephone | 707-981-8604
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Fax | 707-981-8647
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Authorized Official
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Title or Position | OWNER
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Name | MR. LOREN K KIMBLE
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Credential | PT, DPT
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Telephone | 415-425-5206
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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