Healthcare Provider Details

I. General information

NPI: 1336529171
Provider Name (Legal Business Name): KRISTOPHER KEARNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2015
Last Update Date: 06/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 NEIL DR
ROANOKE VA
24019-3411
US

IV. Provider business mailing address

PO BOX 262
SALEM VA
24153-0262
US

V. Phone/Fax

Practice location:
  • Phone: 540-355-8120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019012429
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: