MEDICARE: MRS. KIMBERLEE JANE VICKERS P.T.

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	PT0008682	FL

General Provider Information

NPI Number	:	1952524480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLEE JANE VICKERS P.T.

Provider Business Mailing Address
First Line	:	11738 SUMMER SPRINGS DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-4074
Country	:	US
Telephone Number	:	813-363-9098
Fax Number	:

Provider Business Practice Location Address
First Line	:	11738 SUMMER SPRINGS DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-4074
Country	:	US
Telephone Number	:	813-363-9098
Fax Number	:

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/09/2007

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