Provider Demographics
NPI:1548983497
Name:KIMBERLY CARROLL PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:KIMBERLY CARROLL PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC, CERT DN
Authorized Official - Phone:904-583-2936
Mailing Address - Street 1:2657 AMELIA RD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-9112
Mailing Address - Country:US
Mailing Address - Phone:904-583-2936
Mailing Address - Fax:
Practice Address - Street 1:120 N 2ND ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4191
Practice Address - Country:US
Practice Address - Phone:904-761-8397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy