Healthcare Provider Details

I. General information

NPI: 1285011544
Provider Name (Legal Business Name): SUB-CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5240 1/2 MCCORKLE AVE SE
CHARLESTON WV
25304
US

IV. Provider business mailing address

5240 1/2 MCCORKLE AVE SE
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 304-926-2300
  • Fax: 304-926-2304
Mailing address:
  • Phone: 304-926-2300
  • Fax: 304-926-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22493
License Number StateWV

VIII. Authorized Official

Name: MR. MOHAMAD S KALOU
Title or Position: OWNER
Credential: MD
Phone: 304-926-2300