Healthcare Provider Details

I. General information

NPI: 1003428426
Provider Name (Legal Business Name): SAMUEL GLEN HARRISON II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 CICERONE RD
GANDEEVILLE WV
25243-8664
US

IV. Provider business mailing address

1034 CICERONE RD
GANDEEVILLE WV
25243-8664
US

V. Phone/Fax

Practice location:
  • Phone: 304-577-9145
  • Fax:
Mailing address:
  • Phone: 304-577-9145
  • 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: