Provider Demographics
NPI:1285946392
Name:SPACE, KIMBERLY (DPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SPACE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CRESCENT CENTRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7285
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:514 SAINT JAMES AVE UNIT G
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445
Practice Address - Country:US
Practice Address - Phone:843-642-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8702Medicare PIN