Healthcare Provider Details

I. General information

NPI: 1275993065
Provider Name (Legal Business Name): WESLEY KIRK EADES PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W. WAGNER STREET
ELLENBORO WV
26346-0328
US

IV. Provider business mailing address

415 36TH ST SUITE 100
PARKERSBURG WV
26101-1005
US

V. Phone/Fax

Practice location:
  • Phone: 304-869-3888
  • Fax: 304-869-3444
Mailing address:
  • Phone: 304-917-3660
  • Fax: 304-917-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT31102
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT003518
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: