1356772677 NPI number — DRS. KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC

Table of content: (NPI 1356772677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356772677 NPI number — DRS. KRAJEKIAN,BROCK,HENDERSON & DIPRISCO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRS. KRAJEKIAN,BROCK,HENDERSON & DIPRISCO 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:
1356772677
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 STATION PLACE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HURRICANE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25526-8747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-720-7819
Provider Business Mailing Address Fax Number:
304-345-5080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 GRAND PARK DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PARKERSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-699-5010
Provider Business Practice Location Address Fax Number:
304-553-7268
Provider Enumeration Date:
12/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COYNER
Authorized Official First Name:
LESLEY
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
304-720-7819

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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