Provider Demographics
NPI:1558718247
Name:MASSEY, KIMBERLY A (DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:MASSEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:ROGOWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1845 BUSINESS CENTER DR STE 127
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3434
Mailing Address - Country:US
Mailing Address - Phone:909-890-9030
Mailing Address - Fax:909-890-9030
Practice Address - Street 1:10470 FOOTHILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3754
Practice Address - Country:US
Practice Address - Phone:909-948-0411
Practice Address - Fax:909-948-0511
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA199531Medicare PIN