Healthcare Provider Details

I. General information

NPI: 1740648401
Provider Name (Legal Business Name): KISSITO HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5228 VALLEYPOINTE PKWY BLDG B, SUITE 1
ROANOKE VA
24019-3074
US

IV. Provider business mailing address

5228 VALLEYPOINTE PKWY BLDG B, SUITE 1
ROANOKE VA
24019-3074
US

V. Phone/Fax

Practice location:
  • Phone: 540-265-0322
  • Fax: 540-265-0305
Mailing address:
  • Phone: 540-265-0322
  • Fax: 540-265-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS MATTHEW CLARKE
Title or Position: CEO
Credential:
Phone: 540-265-0322