Provider Demographics
NPI:1689731374
Name:KIMBERLEE J ODONALD PT PC
Entity Type:Organization
Organization Name:KIMBERLEE J ODONALD PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ODONALD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-754-7040
Mailing Address - Street 1:1330 W WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2190
Mailing Address - Country:US
Mailing Address - Phone:616-754-7040
Mailing Address - Fax:616-754-7888
Practice Address - Street 1:1330 W WASHINGTON
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2190
Practice Address - Country:US
Practice Address - Phone:616-754-7040
Practice Address - Fax:616-754-7888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2679020Medicaid
MI30435OtherBLUE CROSS BLUE SHIELD
MI2679020Medicaid