Healthcare Provider Details

I. General information

NPI: 1982528477
Provider Name (Legal Business Name): HENRY THOMAS VAN PIETERSOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MACCORKLE AVE SE # 201
CHARLESTON WV
25304-1099
US

IV. Provider business mailing address

2300 MACCORKLE AVE SE # 201
CHARLESTON WV
25304-1099
US

V. Phone/Fax

Practice location:
  • Phone: 800-995-4682
  • Fax:
Mailing address:
  • Phone: 800-995-4682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: