Healthcare Provider Details

I. General information

NPI: 1356426944
Provider Name (Legal Business Name): JUSTICE MEDICAL COMPLEX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR BOX 330 US HWY 52
KERMIT WV
25669
US

IV. Provider business mailing address

PO BOX 837
KERMIT WV
25674-0837
US

V. Phone/Fax

Practice location:
  • Phone: 304-393-4004
  • Fax: 304-393-4167
Mailing address:
  • Phone: 304-393-4004
  • Fax: 304-393-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21730
License Number StateWV

VIII. Authorized Official

Name: DEBRA JUSTICE
Title or Position: OWNER
Credential:
Phone: 304-393-4004