Provider Demographics
NPI:1114564655
Name:KABOLE, BIIKO L (PTA)
Entity Type:Individual
Prefix:
First Name:BIIKO
Middle Name:L
Last Name:KABOLE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 PINEBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-5621
Mailing Address - Country:US
Mailing Address - Phone:850-377-1527
Mailing Address - Fax:
Practice Address - Street 1:5827 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-1763
Practice Address - Country:US
Practice Address - Phone:850-983-8973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29779225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant