Provider Demographics
NPI:1518433028
Name:KING, KIMBERLY (KIM) FOWLER (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY (KIM)
Middle Name:FOWLER
Last Name:KING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 MONROE DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-9731
Mailing Address - Country:US
Mailing Address - Phone:864-918-7265
Mailing Address - Fax:863-295-3297
Practice Address - Street 1:334 MONROE DR
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-9731
Practice Address - Country:US
Practice Address - Phone:864-918-7265
Practice Address - Fax:864-295-3297
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19072251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC05Medicaid