Provider Demographics
NPI:1497841621
Name:LESLIE K MCKIBBEN RPT ASSOC
Entity Type:Organization
Organization Name:LESLIE K MCKIBBEN RPT ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCKIBBEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:321-259-5592
Mailing Address - Street 1:4640 WHIPPLE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7661
Mailing Address - Country:US
Mailing Address - Phone:321-259-5592
Mailing Address - Fax:321-259-5592
Practice Address - Street 1:4640 WHIPPLE HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7661
Practice Address - Country:US
Practice Address - Phone:321-259-5592
Practice Address - Fax:321-259-5592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL5166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL881511900Medicaid