MEDICARE: KENNY RAY KIMBALL II PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	006743	KY

General Provider Information

NPI Number	:	1184099103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNY RAY KIMBALL II PT, DPT

Provider Business Mailing Address
First Line	:	249 LOVERS LN
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42141-1000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 N RACE ST
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42141-3473
Country	:	US
Telephone Number	:	270-651-7882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2015
Last Update Date	:	12/02/2015

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