Healthcare Provider Details

I. General information

NPI: 1760273429
Provider Name (Legal Business Name): DEREK KASHOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 INDUSTRIAL PARK RD
MAXWELTON WV
24957-8066
US

IV. Provider business mailing address

13175 MIDLAND TRL W
CRAWLEY WV
24931-7010
US

V. Phone/Fax

Practice location:
  • Phone: 304-497-0500
  • Fax:
Mailing address:
  • Phone: 304-646-5664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: