Healthcare Provider Details

I. General information

NPI: 1831645464
Provider Name (Legal Business Name): PNB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 ROBERT C BYRD DR SUITE 4
CRAB ORCHARD WV
25827
US

IV. Provider business mailing address

110 GAINES AVE
BECKLEY WV
25801-8687
US

V. Phone/Fax

Practice location:
  • Phone: 304-253-8979
  • Fax:
Mailing address:
  • Phone: 304-222-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANNON HUGHART
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 304-222-1132