Healthcare Provider Details

I. General information

NPI: 1972510873
Provider Name (Legal Business Name): INTEGRATED HEALTH CARE PROVIDERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BROOKS ST STE 200
CHARLESTON WV
25301-1848
US

IV. Provider business mailing address

415 MORRIS ST STE 304
CHARLESTON WV
25301-1853
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1930
  • Fax:
Mailing address:
  • Phone: 304-388-7783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFF GOODE
Title or Position: PRESIDENT
Credential: PT, MBA
Phone: 304-388-7783