NPIMap

Organization Active NPI

Koda Physical Therapy and Sports Performance

  • Physical Therapy Clinic/Center
  • Petaluma, CA
National Provider Identifier
1356797542
Registry record updated Jun 10, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
Legal business name
KODA PHYSICAL THERAPY AND SPORTS PERFORMANCE
Practice address
1600 Corporate Cir
Petaluma, CA 94954-6912
Phone
(707) 981-8604
Fax
(707) 981-8647
NPI assigned
May 6, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 10, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Loren K Kimble, PT, DPTNPI 1336473362
Title
Owner
Phone
(415) 425-5206

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X Primary

Addresses

Primary practice location

1600 Corporate Cir
Petaluma, CA 94954-6912

Mailing address

1600 Corporate Cir
Petaluma, CA 94954-6912
Phone (707) 981-8604

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170412000160 CA Part B Supplier - Physical/Occupational Therapy Group in Private Practice 6103102884 Receives reassigned benefits from 4 practitioners
Practice locations: Petaluma, CA

National Provider Directory

National Provider Directory

Locations

1600 Corporate Cir
Petaluma, CA 94954
Phone (707) 981-8604

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1462492800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623283200000",
    "number": "1356797542",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1600 CORPORATE CIR",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949546912",
            "telephone_number": "707-981-8604",
            "fax_number": "707-981-8647"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 CORPORATE CIR",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949546912",
            "telephone_number": "707-981-8604",
            "fax_number": "707-981-8647"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KODA PHYSICAL THERAPY AND SPORTS PERFORMANCE",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-05-06",
        "last_updated": "2021-06-10",
        "certification_date": "2021-06-10",
        "status": "A",
        "authorized_official_last_name": "KIMBLE",
        "authorized_official_first_name": "LOREN",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "415-425-5206",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PT, DPT"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Petaluma, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.