Provider Demographics
NPI:1265960090
Name:EVERSOLE, KILEY S
Entity type:Individual
Prefix:
First Name:KILEY
Middle Name:S
Last Name:EVERSOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-0474
Mailing Address - Country:US
Mailing Address - Phone:406-312-9967
Mailing Address - Fax:406-519-5542
Practice Address - Street 1:2230 N RESERVE ST STE 300
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1364
Practice Address - Country:US
Practice Address - Phone:406-312-9967
Practice Address - Fax:406-519-5542
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-12931225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist