Provider Demographics
NPI:1598105322
Name:ZIMMERMAN, KYLE ISAAC (ATC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ISAAC
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 S DEKALB ST
Mailing Address - Street 2:516
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-8768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28017-9797
Practice Address - Country:US
Practice Address - Phone:704-406-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2255A2300X
GAAT0019172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer