Healthcare Provider Details

I. General information

NPI: 1477892180
Provider Name (Legal Business Name): HDK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 03/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 PEBBLESTONE DR
BECKLEY WV
25801-9524
US

IV. Provider business mailing address

118 PEBBLESTONE DR
BECKLEY WV
25801-9524
US

V. Phone/Fax

Practice location:
  • Phone: 304-237-4836
  • Fax:
Mailing address:
  • Phone: 304-237-4836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. AUSTIN D. LILLY
Title or Position: ORGANIZER
Credential:
Phone: 304-237-4836