=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962626374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYMBAL RAI HURST PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | REFLECTX STAFFING 250 INTERNATIONAL PKWY
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-833-8815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7413 RONNIE AVE
-----------------------------------------------------
City | WEST PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42086-9536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A02017
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------