Provider Demographics
NPI:1639335540
Name:CHURCH, KELBY R (PT, DPT, OCS, ATC)
Entity Type:Individual
Prefix:
First Name:KELBY
Middle Name:R
Last Name:CHURCH
Suffix:
Gender:M
Credentials:PT, DPT, OCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 36TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3660
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:174 N STATE ROUTE 2 STE 2
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1604
Practice Address - Country:US
Practice Address - Phone:304-447-6778
Practice Address - Fax:304-447-6779
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT 002702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
WV3810012940Medicaid