Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 000097 | WV |
NPI | 1023145661 |
---|---|
Provider Name | Mr. David Kelley |
First Address | South Charleston, WV 25309 |
Second Address | Charleston, WV 25311 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2007 |
Last Update Date | 08/07/2007 |