Healthcare Provider Details

I. General information

NPI: 1144340787
Provider Name (Legal Business Name): APPLACHAIN PAIN THERAPY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4407 MACCORKLE AVE SE
CHARLESTON WV
25304-2505
US

IV. Provider business mailing address

4407 MACCORKLE AVE SE
CHARLESTON WV
25304-2505
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-2922
  • Fax: 304-926-8009
Mailing address:
  • Phone: 304-925-2922
  • Fax: 304-926-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number11322
License Number StateWV

VIII. Authorized Official

Name: DR. JOSIAH KELLEY LILLY
Title or Position: OWNER
Credential: MD
Phone: 304-925-2922