Healthcare Provider Details

I. General information

NPI: 1174445290
Provider Name (Legal Business Name): JEREMIAH BLAINE LANCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 VIRGINIA ST E STE 400
CHARLESTON WV
25301-2835
US

IV. Provider business mailing address

505 55TH ST UNIT B
VIENNA WV
26105-3215
US

V. Phone/Fax

Practice location:
  • Phone: 681-313-1759
  • Fax: 844-800-3954
Mailing address:
  • Phone: 681-313-1759
  • Fax: 844-800-3954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number42618
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: