Provider Demographics
NPI:1356797542
Name:KODA PHYSICAL THERAPY AND SPORTS PERFORMANCE
Entity type:Organization
Organization Name:KODA PHYSICAL THERAPY AND SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:415-425-5206
Mailing Address - Street 1:1600 CORPORATE CIR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6912
Mailing Address - Country:US
Mailing Address - Phone:707-981-8604
Mailing Address - Fax:707-981-8647
Practice Address - Street 1:1600 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6912
Practice Address - Country:US
Practice Address - Phone:707-981-8604
Practice Address - Fax:707-981-8647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy