Provider Demographics
NPI:1720125438
Name:KUDLOCK, TIM J (PT)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:J
Last Name:KUDLOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E JACKSON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2176
Mailing Address - Country:US
Mailing Address - Phone:605-722-6880
Mailing Address - Fax:605-722-6889
Practice Address - Street 1:215 E JACKSON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2176
Practice Address - Country:US
Practice Address - Phone:605-722-6880
Practice Address - Fax:605-722-6889
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5831434Medicaid
SD0041172OtherBLUE CROSS BLUE SHIELD SD
SD5831434Medicaid