Provider Demographics
NPI:1972543304
Name:KEIFRIDER, KIM R (PT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:KEIFRIDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-3842
Mailing Address - Country:US
Mailing Address - Phone:828-489-2422
Mailing Address - Fax:
Practice Address - Street 1:100 ELKS CLUB RD.
Practice Address - Street 2:FAX AND EMAIL: KIMRK@COMPORIUM.NET
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712
Practice Address - Country:US
Practice Address - Phone:828-489-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10408225100000X, 225100000X
FLPT14455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5P276Medicare ID - Type UnspecifiedMEDICARE NUMBER