Healthcare Provider Details

I. General information

NPI: 1407258148
Provider Name (Legal Business Name): RICK POLING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MARKET ST.
GRANTSVILLE WV
26147
US

IV. Provider business mailing address

PO BOX 619
GRANTSVILLE WV
26147-0619
US

V. Phone/Fax

Practice location:
  • Phone: 304-354-7017
  • Fax: 304-354-6859
Mailing address:
  • Phone: 304-354-7017
  • Fax: 304-354-6859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number10359463
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: