Healthcare Provider Details

I. General information

NPI: 1790083475
Provider Name (Legal Business Name): VA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BUTLER AVE
MARTINSBURG WV
25405-9990
US

IV. Provider business mailing address

PO BOX 501
KEARNEYSVILLE WV
25430-0501
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0811
  • Fax:
Mailing address:
  • Phone: 304-876-3529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number59640
License Number StateWV

VIII. Authorized Official

Name: MRS. KIMBERLY MCDIFFITT
Title or Position: MEDICAL STAFF DIRECTOR
Credential: CPMSM,CPCS
Phone: 304-263-0811