Healthcare Provider Details

I. General information

NPI: 1427651843
Provider Name (Legal Business Name): KILEY COLEMAN GIBBS PEDIATRIC PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21631 RIDGETOP CIR STE 225A
STERLING VA
20166-6742
US

IV. Provider business mailing address

19208 DEER PATH
KNOXVILLE MD
21758-1344
US

V. Phone/Fax

Practice location:
  • Phone: 240-377-6179
  • Fax: 240-397-5370
Mailing address:
  • Phone: 240-377-6179
  • Fax: 240-397-5370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KILEY C GIBBS
Title or Position: OWNER/ PHYSICAL THERAPIST
Credential: PT, DPT, MA, PCS
Phone: 240-377-6179