1093220303 NPI number — WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC

Table of content: (NPI 1093220303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093220303 NPI number — WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, 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:
Provider Other Organization Name Type Code:
6
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:
1093220303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1464 JEFFERSON ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24901-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-645-3220
Provider Business Mailing Address Fax Number:
304-793-2491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
356 NICHOLAS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUPERT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-645-3220
Provider Business Practice Location Address Fax Number:
304-645-4103
Provider Enumeration Date:
12/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NEMCIK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
304-645-3220

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  36604 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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