Healthcare Provider Details

I. General information

NPI: 1568662609
Provider Name (Legal Business Name): FAYETTE COUNTY BOARD OF EDUCATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FAYETTE AVE
FAYETTEVILLE WV
25840-1219
US

IV. Provider business mailing address

404 OLD MAIN DR
SUMMERSVILLE WV
26651-1360
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-1176
  • Fax: 304-574-3643
Mailing address:
  • Phone: 304-872-6440
  • Fax: 304-872-6442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateWV

VIII. Authorized Official

Name: MS. BILLIE JEAN RADER
Title or Position: MEDICAID SPECIALIST
Credential:
Phone: 304-872-6440