MEDICARE: KIM OLIVER VISPERAS ROMERO DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	003616	WV
2	225100000X	Physical Therapist	PT003616	WV

General Provider Information

NPI Number	:	1073960191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM OLIVER VISPERAS ROMERO DPT

Provider Business Mailing Address
First Line	:	400 ASSOCIATION DR STE 102
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-1298
Country	:	US
Telephone Number	:	304-388-0015
Fax Number	:	304-388-0019

Provider Business Practice Location Address
First Line	:	3948 TEAYS VALLEY RD STE 1320
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-8728
Country	:	US
Telephone Number	:	304-757-1764
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	08/28/2023

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