Provider Demographics
NPI:1114471083
Name:TAN, KIM KELBY SIA (RPT)
Entity Type:Individual
Prefix:MR
First Name:KIM KELBY
Middle Name:SIA
Last Name:TAN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3452 LAKE LYNDA DR STE 2001
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1430
Mailing Address - Country:US
Mailing Address - Phone:800-774-7785
Mailing Address - Fax:
Practice Address - Street 1:3452 LAKE LYNDA DR STE 2001
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-1430
Practice Address - Country:US
Practice Address - Phone:800-774-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1253233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1253233OtherTEXAS PHYSICAL THERAPY LICENSE