Healthcare Provider Details

I. General information

NPI: 1104748698
Provider Name (Legal Business Name): EDWARD WINE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 RAILROAD ST
FLATWOODS WV
26621-2101
US

IV. Provider business mailing address

89 ROSS RUN RD
FLATWOODS WV
26621-8169
US

V. Phone/Fax

Practice location:
  • Phone: 304-701-8627
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: