MEDICARE: KILEY ROSE DEFIBAUGH OTR/L

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	225XP0019X	Physical Rehabilitation Occupational Therapist	1894	WV

General Provider Information

NPI Number	:	1750921987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KILEY ROSE DEFIBAUGH OTR/L

Provider Business Mailing Address
First Line	:	4906 BOXWOOD DR
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25306-6302
Country	:	US
Telephone Number	:	304-830-1064
Fax Number	:

Provider Business Practice Location Address
First Line	:	4906 BOXWOOD DR
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25306-6302
Country	:	US
Telephone Number	:	304-830-1064
Fax Number	:

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

Provider Enumeration Date	:	01/15/2020
Last Update Date	:	01/15/2020

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