Healthcare Provider Details

I. General information

NPI: 1558846261
Provider Name (Legal Business Name): THE CARSON BLACK LUNG RESEARCH AND EDUCATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40518 W MORGAN AVE
PENNINGTON GAP VA
24277-1822
US

IV. Provider business mailing address

850 RIVERVIEW AVE FL 3
PINEVILLE KY
40977-1452
US

V. Phone/Fax

Practice location:
  • Phone: 252-452-6075
  • Fax: 276-318-0298
Mailing address:
  • Phone: 252-452-4080
  • Fax: 276-318-0298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RODNEY TERRY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 252-452-6075