Healthcare Provider Details

I. General information

NPI: 1639616006
Provider Name (Legal Business Name): MAIN STREET ADDICTION CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 MAIN ST
LOGAN WV
25601-3944
US

IV. Provider business mailing address

204 MAIN ST
LOGAN WV
25601-3944
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-3400
  • Fax: 304-752-3400
Mailing address:
  • Phone: 304-752-3400
  • Fax: 304-752-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number1489
License Number StateWV

VIII. Authorized Official

Name: KENNETH W. SELLS
Title or Position: OWNER
Credential: D.O.
Phone: 304-752-3400