Provider Demographics
NPI:1063666337
Name:KIBROM, SAMUEL A (PT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:KIBROM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 GOVERNOR MANLY WAY
Mailing Address - Street 2:SUITE 309
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8599
Mailing Address - Country:US
Mailing Address - Phone:919-562-9410
Mailing Address - Fax:
Practice Address - Street 1:11200 GOVERNOR MANLY WAY
Practice Address - Street 2:SUITE 309
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8599
Practice Address - Country:US
Practice Address - Phone:919-562-9410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist