Healthcare Provider Details

I. General information

NPI: 1861848384
Provider Name (Legal Business Name): TRENT WYSOCKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 KITCHENS ORCHARD RD
FALLING WATERS WV
25419-3872
US

IV. Provider business mailing address

1414 KITCHENS ORCHARD RD
FALLING WATERS WV
25419-3872
US

V. Phone/Fax

Practice location:
  • Phone: 304-575-2065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2001-0782
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: