Healthcare Provider Details

I. General information

NPI: 1376809186
Provider Name (Legal Business Name): RALEIGH COUNTY COMMISSION ON AGING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 S KANAWHA ST
BECKLEY WV
25801-6239
US

IV. Provider business mailing address

1614 S KANAWHA ST
BECKLEY WV
25801-6239
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-1397
  • Fax: 304-252-9360
Mailing address:
  • Phone: 304-255-1397
  • Fax: 304-252-9360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateWV

VIII. Authorized Official

Name: MR. JACK TANNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 304-255-1397