Provider Demographics
NPI:1336473362
Name:KIMBLE, LOREN KODA (PT)
Entity Type:Individual
Prefix:MR
First Name:LOREN
Middle Name:KODA
Last Name:KIMBLE
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 1:1600 CORPORATE CIR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6912
Mailing Address - Country:US
Mailing Address - Phone:707-981-8604
Mailing Address - Fax:707-981-8647
Practice Address - Street 1:1600 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6912
Practice Address - Country:US
Practice Address - Phone:707-981-8604
Practice Address - Fax:707-981-8647
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist