1821700576 NPI number — MR. ROY CLIFFORD MASSEY IV PRSS

Table of content: MR. ROY CLIFFORD MASSEY IV PRSS (NPI 1821700576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821700576 NPI number — MR. ROY CLIFFORD MASSEY IV PRSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSEY
Provider First Name:
ROY
Provider Middle Name:
CLIFFORD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
IV
Provider Credential Text:
PRSS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1821700576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8413
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25303-0413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-200-3472
Provider Business Mailing Address Fax Number:
304-926-1290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4202 MALDEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALDEN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25306-6442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
681-208-3750
Provider Business Practice Location Address Fax Number:
304-926-1260
Provider Enumeration Date:
12/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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