Healthcare Provider Details

I. General information

NPI: 1225483571
Provider Name (Legal Business Name): KEVIN HENNENHOEFER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2016
Last Update Date: 04/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N JEFFERSON ST
LEWISBURG WV
24901-1177
US

IV. Provider business mailing address

400 N JEFFERSON ST
LEWISBURG WV
24901-1177
US

V. Phone/Fax

Practice location:
  • Phone: 304-645-3220
  • Fax: 304-647-1273
Mailing address:
  • Phone: 304-645-3220
  • Fax: 304-647-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: