Provider Demographics
NPI:1649222084
Name:WILLMORE, KEVIN K (DPT)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:K
Last Name:WILLMORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3782 HIGHWAY 95
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8124
Mailing Address - Country:US
Mailing Address - Phone:928-763-0807
Mailing Address - Fax:
Practice Address - Street 1:3782 HIGHWAY 95
Practice Address - Street 2:SUITE 2
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8124
Practice Address - Country:US
Practice Address - Phone:928-763-0807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4038225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ79130Medicare PIN