Healthcare Provider Details

I. General information

NPI: 1508291477
Provider Name (Legal Business Name): DUNBAR THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 DUNBAR AVE
DUNBAR WV
25064-2920
US

IV. Provider business mailing address

1313 DUNBAR AVE
DUNBAR WV
25064-2920
US

V. Phone/Fax

Practice location:
  • Phone: 304-400-4896
  • Fax: 304-400-4897
Mailing address:
  • Phone: 304-400-4896
  • Fax: 304-400-4897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberOTR/L 1092
License Number StateWV

VIII. Authorized Official

Name: JASPER BANZON
Title or Position: OWNER
Credential: OTR/L
Phone: 304-654-6892