Healthcare Provider Details

I. General information

NPI: 1700079704
Provider Name (Legal Business Name): WV SPINE AND PAIN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 GOFF MOUNTAIN RD SUITE 16
CROSS LANES WV
25313-6602
US

IV. Provider business mailing address

PO BOX 58125
CHARLESTON WV
25358-0125
US

V. Phone/Fax

Practice location:
  • Phone: 304-561-7879
  • Fax: 304-307-6619
Mailing address:
  • Phone: 304-561-7879
  • Fax: 304-307-6619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number20962
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number20962
License Number StateWV

VIII. Authorized Official

Name: DR. WEIXING WILLIAM GUO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 304-561-7879