Provider Demographics
NPI:1568879963
Name:RODGERS, KIMBER (MAT, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KIMBER
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:MAT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:WOLFFORTH
Mailing Address - State:TX
Mailing Address - Zip Code:79382-0100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 N DOWDEN RD
Practice Address - Street 2:
Practice Address - City:WOLFFORTH
Practice Address - State:TX
Practice Address - Zip Code:79382-5508
Practice Address - Country:US
Practice Address - Phone:806-866-4480
Practice Address - Fax:806-866-4038
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0808020962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer