Healthcare Provider Details

I. General information

NPI: 1154712032
Provider Name (Legal Business Name): CATHY BOYD PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804A HARPER RD
BECKLEY WV
25801-3331
US

IV. Provider business mailing address

PO BOX 5356
BECKLEY WV
25801-7504
US

V. Phone/Fax

Practice location:
  • Phone: 304-250-6047
  • Fax: 304-250-6048
Mailing address:
  • Phone: 304-250-6047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77359
License Number StateWV

VIII. Authorized Official

Name: CHRISTOPHER GROSE
Title or Position: CEO
Credential: DC
Phone: 304-250-6047