Provider Demographics
NPI:1891034575
Name:KIDABILITY PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:KIDABILITY PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-230-0402
Mailing Address - Street 1:PO BOX 521504
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99652-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6406 S. GONDER ROAD
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:AK
Practice Address - Zip Code:99652
Practice Address - Country:US
Practice Address - Phone:907-230-0402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPT11592251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty