Provider Demographics
NPI:1023206760
Name:ANDERSON, KIM G (LMT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:G
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:11333 VERA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4159
Mailing Address - Country:US
Mailing Address - Phone:904-504-4563
Mailing Address - Fax:904-751-3906
Practice Address - Street 1:304 PONCE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3863
Practice Address - Country:US
Practice Address - Phone:904-504-4563
Practice Address - Fax:904-751-3906
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLMA30630225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist