Healthcare Provider Details

I. General information

NPI: 1023858149
Provider Name (Legal Business Name): HEIDI MOLGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1464 JEFFERSON ST N
LEWISBURG WV
24901-1380
US

IV. Provider business mailing address

1320 MAPLEWOOD AVE
RONCEVERTE WV
24970-8016
US

V. Phone/Fax

Practice location:
  • Phone: 304-645-3220
  • Fax:
Mailing address:
  • Phone: 949-422-6516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number204D00000X
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: