Healthcare Provider Details

I. General information

NPI: 1386786796
Provider Name (Legal Business Name): TRI-STATE ALLERGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 LEXINGTON AVE STE 105
ASHLAND KY
41101-2807
US

IV. Provider business mailing address

1001 20TH ST
HUNTINGTON WV
25703-2019
US

V. Phone/Fax

Practice location:
  • Phone: 304-529-6100
  • Fax: 304-529-0229
Mailing address:
  • Phone: 304-529-6100
  • Fax: 304-529-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW C WILSON
Title or Position: PRESIDENT
Credential: MD
Phone: 304-529-6100