Healthcare Provider Details

I. General information

NPI: 1972315356
Provider Name (Legal Business Name): MS. KIMBERLY SKOTKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5727 BIGGER ROAD
KETTERING OH
45440
US

IV. Provider business mailing address

924 RENWOOD DRIVE KETTERING OHIO 45429
KETTERING OH
45429
US

V. Phone/Fax

Practice location:
  • Phone: 937-949-3715
  • Fax:
Mailing address:
  • Phone: 937-478-6641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.018745
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: