Provider Demographics
NPI:1871131706
Name:HO, KIMBERLY T (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:HO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUMIKO
Other - Last Name:TATSUMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2643 DIETRICH DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1358
Mailing Address - Country:US
Mailing Address - Phone:714-585-2330
Mailing Address - Fax:
Practice Address - Street 1:2600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5941
Practice Address - Country:US
Practice Address - Phone:714-585-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA6496225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty