Healthcare Provider Details

I. General information

NPI: 1336956648
Provider Name (Legal Business Name): INJURY CENTER OF WV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PROFESSIONAL PL
BRIDGEPORT WV
26330-4599
US

IV. Provider business mailing address

3000 CORPORATE EXCHANGE DR STE 110
COLUMBUS OH
43231-7689
US

V. Phone/Fax

Practice location:
  • Phone: 681-519-9779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT JOHN BROOKS
Title or Position: OWNER
Credential: DC
Phone: 614-619-6965