Provider Demographics
NPI:1639289945
Name:RYDER, KIMBERLY C (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:RYDER
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 1:16 OFFICE PARK DR
Mailing Address - Street 2:SUITE 21
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-6020
Mailing Address - Country:US
Mailing Address - Phone:601-296-9191
Mailing Address - Fax:601-296-9190
Practice Address - Street 1:16 OFFICE PARK DR
Practice Address - Street 2:SUITE 21
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-6020
Practice Address - Country:US
Practice Address - Phone:601-296-9191
Practice Address - Fax:601-296-9190
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08832052Medicaid
MSP95661Medicare UPIN