Basic Information
| Provider Information | |||||||||
| NPI: | 1639335540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | KELBY | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | PT, DPT, OCS, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 36TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261011005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173660 | ||||||||
| FaxNumber: | 3049173674 | ||||||||
| Practice Location | |||||||||
| Address1: | 174 N STATE ROUTE 2 STE 2 | ||||||||
| Address2: | |||||||||
| City: | NEW MARTINSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261551604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044476778 | ||||||||
| FaxNumber: | 3044476779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2008 | ||||||||
| LastUpdateDate: | 12/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 002702 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | OH | MEDICAID | 3810012940 | 05 | WV | MEDICAID |