Healthcare Provider Details

I. General information

NPI: 1013016849
Provider Name (Legal Business Name): CURTIS BRENT PACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 ROOSEVELT BLVD
ELEANOR WV
25070
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9816
US

V. Phone/Fax

Practice location:
  • Phone: 304-586-0001
  • Fax: 304-586-0079
Mailing address:
  • Phone: 304-757-6999
  • Fax: 304-757-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1450
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: