Healthcare Provider Details

I. General information

NPI: 1821899170
Provider Name (Legal Business Name): KAITLYN RAYNE REXROAD OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2025
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 MORGANTOWN AVE
FAIRMONT WV
26554-4331
US

IV. Provider business mailing address

709 MORGANTOWN AVE
FAIRMONT WV
26554-4331
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-4721
  • Fax: 304-366-4847
Mailing address:
  • Phone: 304-366-4721
  • Fax: 304-366-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3054-IOD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: