Healthcare Provider Details

I. General information

NPI: 1609996792
Provider Name (Legal Business Name): SUREKHA S GAJENDRAGADKAR RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 YELLOW WOOD WAY
BECKLEY WV
25801-7126
US

IV. Provider business mailing address

9 YELLOW WOOD WAY
BECKLEY WV
25801-7126
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-2376
  • Fax: 304-255-7120
Mailing address:
  • Phone: 304-255-2376
  • Fax: 304-255-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number000398
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: