Provider Demographics
NPI:1396786513
Name:KOLB, VIKKI (LMT)
Entity type:Individual
Prefix:
First Name:VIKKI
Middle Name:
Last Name:KOLB
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:VIKKI
Other - Middle Name:
Other - Last Name:KOLB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:2060 FAIRPORT NINE MILE PT RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1749
Mailing Address - Country:US
Mailing Address - Phone:585-261-8105
Mailing Address - Fax:
Practice Address - Street 1:2060 FAIRPORT NINE MILE PT RD
Practice Address - Street 2:SUITE 403
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1749
Practice Address - Country:US
Practice Address - Phone:585-261-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011919225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY109853GGMedicare UPIN