Healthcare Provider Details

I. General information

NPI: 1104204387
Provider Name (Legal Business Name): KALI KIGHT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 MONONGAHELA BLVD
MORGANTOWN WV
26505
US

IV. Provider business mailing address

3450 MONONGAHELA BLVD
MORGANTOWN WV
26505-3043
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-9868
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005366
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001590
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: