Healthcare Provider Details

I. General information

NPI: 1326623869
Provider Name (Legal Business Name): CHARLES POMEROY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KEENAN HILL ST
CEDAR GROVE WV
25039
US

IV. Provider business mailing address

PO BOX 686
CEDAR GROVE WV
25039-0686
US

V. Phone/Fax

Practice location:
  • Phone: 304-982-3235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: