Provider Demographics
NPI:1942277603
Name:SHORE, KIMBERLY JOANNE (RPT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JOANNE
Last Name:SHORE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 S PENDLETON ST STE B
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3084
Mailing Address - Country:US
Mailing Address - Phone:864-855-7030
Mailing Address - Fax:
Practice Address - Street 1:1118 CORNELIA RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3317
Practice Address - Country:US
Practice Address - Phone:864-225-8321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC4041174400000X
SC4041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1071Medicaid
SCGP4273Medicaid