Provider Demographics
NPI:1205371119
Name:KIRKHAM, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KIRKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX N
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-0376
Mailing Address - Country:US
Mailing Address - Phone:949-290-7144
Mailing Address - Fax:
Practice Address - Street 1:800 LANTERN CREST WAY
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4646
Practice Address - Country:US
Practice Address - Phone:949-290-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-31
Last Update Date:2016-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant