Provider Demographics
NPI:1922322841
Name:BORDELON, KIMBERLY (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BORDELON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-2430
Mailing Address - Country:US
Mailing Address - Phone:318-240-7770
Mailing Address - Fax:
Practice Address - Street 1:503 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2430
Practice Address - Country:US
Practice Address - Phone:318-240-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1678225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist