Healthcare Provider Details

I. General information

NPI: 1407780091
Provider Name (Legal Business Name): EDDIE CARL BLANKENSHIP JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TWENTY ONE HOLLOW
KOPPERSTON WV
24854
US

IV. Provider business mailing address

PO BOX 892
OCEANA WV
24870-0892
US

V. Phone/Fax

Practice location:
  • Phone: 304-683-1869
  • Fax:
Mailing address:
  • Phone: 304-683-1869
  • 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: