MEDICARE: MOUNTAIN STATE WELLNESS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor		WV

General Provider Information

NPI Number	:	1023348448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN STATE WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	965 HARTMAN RUN RD
Second Line	:	SUITE 1101
City	:	MORGANTOWN
State	:	WV
Zip	:	26505-7700
Country	:	US
Telephone Number	:	304-292-7740
Fax Number	:

Provider Business Practice Location Address
First Line	:	965 HARTMAN RUN RD
Second Line	:	SUITE 1101
City	:	MORGANTOWN
State	:	WV
Zip	:	26505-7700
Country	:	US
Telephone Number	:	304-292-7740
Fax Number	:

Authorized Official
Title or Position	:	MEMBER/DIRECT OWNER
Name	:	DR. LUCAS C WATTERSON
Credential	:	D.C.
Telephone Number	:	304-292-7740

Provider Enumeration Date	:	01/07/2010
Last Update Date	:	01/07/2010

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