1609194505 NPI number — NEW RIVER HEALTH ASSOCIATION, INC.

Table of content: PETER WALLACE FONTENOT (NPI 1942316096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609194505 NPI number — NEW RIVER HEALTH ASSOCIATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW RIVER HEALTH ASSOCIATION, 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:
1609194505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
497 MALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK HILL
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25901-6216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-469-2905
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 W. MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOPHIA
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-683-3809
Provider Business Practice Location Address Fax Number:
304-683-5761
Provider Enumeration Date:
05/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MARISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
304-469-2905

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  SO0552404 , 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)

  • Identifier: SP0552404 . This is a "BOARD OF PHARMACY" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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