Provider Demographics
NPI:1588491773
Name:KISAMORE, RUBY
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:KISAMORE
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 1:17 MOORE STATION RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:WV
Mailing Address - Zip Code:26283-8835
Mailing Address - Country:US
Mailing Address - Phone:304-478-4545
Mailing Address - Fax:
Practice Address - Street 1:17 MOORE STATION RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:WV
Practice Address - Zip Code:26283-8835
Practice Address - Country:US
Practice Address - Phone:304-478-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide