Healthcare Provider Details

I. General information

NPI: 1629018320
Provider Name (Legal Business Name): KELLY J. ROUSH ICENHOWER DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 4TH AVE
GALLIPOLIS OH
45631-1612
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-5244
  • Fax: 740-446-5565
Mailing address:
  • Phone: 740-446-5244
  • Fax: 740-446-5565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2510
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2510
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: