Healthcare Provider Details

I. General information

NPI: 1952815185
Provider Name (Legal Business Name): BONITA RAE MCCLUNG PCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. BONITA RAE ROSE

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 SETTLEMENT DRIVE
CHARMCO WV
25958
US

IV. Provider business mailing address

324 SETTLEMENT DRIVE
CHARMCO WV
25958
US

V. Phone/Fax

Practice location:
  • Phone: 304-438-5677
  • Fax:
Mailing address:
  • Phone: 304-438-5677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: