Healthcare Provider Details

I. General information

NPI: 1366388266
Provider Name (Legal Business Name): MATTHEW LARK WILLIAMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 SALTPETRE RD
FORT GAY WV
25514-8543
US

IV. Provider business mailing address

802 SALTPETRE RD
FORT GAY WV
25514-8543
US

V. Phone/Fax

Practice location:
  • Phone: 304-453-9176
  • Fax:
Mailing address:
  • Phone: 304-453-9176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: