Healthcare Provider Details

I. General information

NPI: 1457536492
Provider Name (Legal Business Name): DR. RAGHDA SAHLOUL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE SUITE 606
CHARLESTON WV
25304
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE SUITE 606
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-8665
  • Fax: 304-345-8662
Mailing address:
  • Phone: 304-345-8665
  • Fax: 304-345-8662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number20791
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number20791
License Number StateWV

VIII. Authorized Official

Name: DEBORAH ROGERS KINDER
Title or Position: OFFICE MANAGER
Credential:
Phone: 304-345-8665