Provider Demographics
NPI:1215157193
Name:ZIMMERMAN, KYLE S (ATC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:S
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SAGAMORE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-2544
Mailing Address - Country:US
Mailing Address - Phone:203-238-7981
Mailing Address - Fax:
Practice Address - Street 1:119 SAGAMORE RD
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-2544
Practice Address - Country:US
Practice Address - Phone:203-238-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000098OtherSTATE LICENSE