Healthcare Provider Details

I. General information

NPI: 1174032338
Provider Name (Legal Business Name): LEAD ACADEMY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 VALLEY VIEW ST
MIDWAY WV
25878
US

IV. Provider business mailing address

PO BOX 280
MIDWAY WV
25878-0280
US

V. Phone/Fax

Practice location:
  • Phone: 304-573-0661
  • Fax: 304-573-0661
Mailing address:
  • Phone: 304-573-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: DR. EUGENE KIRBY BLANKENSHIP
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 304-573-0661