Provider Demographics
NPI:1457853590
Name:ALLDREDGE, KIM LEWIS
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LEWIS
Last Name:ALLDREDGE
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 1:20664 GOLF CANYON CT
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363-8909
Mailing Address - Country:US
Mailing Address - Phone:209-404-3753
Mailing Address - Fax:
Practice Address - Street 1:1801 H ST STE C-1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1221
Practice Address - Country:US
Practice Address - Phone:209-846-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT108112251X0800X
CA108112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic