Healthcare Provider Details

I. General information

NPI: 1184272155
Provider Name (Legal Business Name): MICHAEL DUANE CARPENTER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 LEE RD
FOLLANSBEE WV
26037-1783
US

IV. Provider business mailing address

14 LEE DR
WHEELING WV
26003-1616
US

V. Phone/Fax

Practice location:
  • Phone: 304-527-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number002246
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: