Provider Demographics
NPI:1346377942
Name:COLEY, KIMMIE L (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMMIE
Middle Name:L
Last Name:COLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 S WICKHAM RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1436
Mailing Address - Country:US
Mailing Address - Phone:321-723-1011
Mailing Address - Fax:321-723-1110
Practice Address - Street 1:635 S WICKHAM RD
Practice Address - Street 2:SUITE 203
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1436
Practice Address - Country:US
Practice Address - Phone:321-723-1011
Practice Address - Fax:321-723-1110
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8196111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
70265ZOtherMEDICARE
FL70265OtherBLUE CROSS BLUE SHIELD FL