Provider Demographics
NPI:1033102199
Name:KIMBALL, GARY C (PT, OCS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 POWELL ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-5245
Mailing Address - Country:US
Mailing Address - Phone:508-747-2823
Mailing Address - Fax:
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1868
Practice Address - Country:US
Practice Address - Phone:781-331-9600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0363731Medicaid
MA0363731Medicaid