Healthcare Provider Details

I. General information

NPI: 1730410101
Provider Name (Legal Business Name): MOUNTAIN HOME PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2010
Last Update Date: 08/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 6TH AVE
HUNTINGTON WV
25701-2421
US

IV. Provider business mailing address

1412 6TH AVE
HUNTINGTON WV
25701-2421
US

V. Phone/Fax

Practice location:
  • Phone: 304-523-4555
  • Fax: 304-525-1736
Mailing address:
  • Phone: 304-523-4555
  • Fax: 304-525-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1507
License Number StateWV

VIII. Authorized Official

Name: MR. DARYL ALLEN WHITE
Title or Position: PRESIDENT
Credential: PHYSICAL THERAPIST
Phone: 304-523-4555