Healthcare Provider Details

I. General information

NPI: 1083501621
Provider Name (Legal Business Name): EVA ICE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 RICHWOOD RUN RD
JACKSONBURG WV
26377-9019
US

IV. Provider business mailing address

68 RICHWOOD RUN RD
JACKSONBURG WV
26377-9019
US

V. Phone/Fax

Practice location:
  • Phone: 304-889-3354
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: