1891999801 NPI number — INTEGRATED HEALTH CARE PROVIDERS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891999801 NPI number — INTEGRATED HEALTH CARE PROVIDERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED HEALTH CARE PROVIDERS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DAVID LEE CANCER CENTER LAB
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891999801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 MORRIS ST STE 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25301-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-388-7783
Provider Business Mailing Address Fax Number:
304-388-7788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 MACCORKLE AVE SE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25304-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-388-8380
Provider Business Practice Location Address Fax Number:
304-388-8388
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOODE
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-388-7783

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0014092000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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