Healthcare Provider Details

I. General information

NPI: 1497110134
Provider Name (Legal Business Name): ROBERT THORNTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4253 SPECKS RUN RD
BUNKER HILL WV
25413-2884
US

IV. Provider business mailing address

4253 SPECKS RUN RD
BUNKER HILL WV
25413-2884
US

V. Phone/Fax

Practice location:
  • Phone: 304-279-6701
  • Fax:
Mailing address:
  • Phone: 304-279-6701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2289-9446
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: