MEDICARE: KIMBERLY MUNGOVAN PT

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	302805	CA

General Provider Information

NPI Number	:	1962122440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MUNGOVAN PT

Provider Business Mailing Address
First Line	:	1650 LYNDON FARM CT STE 300
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-5005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8901 ACTIVITY RD STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4436
Country	:	US
Telephone Number	:	858-566-6673
Fax Number	:	858-566-6803

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

Provider Enumeration Date	:	09/02/2022
Last Update Date	:	09/02/2022

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Directions to “ KIMBERLY MUNGOVAN PT” Practice Location

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