Healthcare Provider Details

I. General information

NPI: 1205322898
Provider Name (Legal Business Name): SAMUEL SEBOK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 KENMORE DR
DANVILLE WV
25053-7133
US

IV. Provider business mailing address

186 1/2 NIGHBERT AVE
LOGAN WV
25601-4003
US

V. Phone/Fax

Practice location:
  • Phone: 304-369-0986
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001019
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: