Healthcare Provider Details

I. General information

NPI: 1275769275
Provider Name (Legal Business Name): JENNIFER E BEVERAGE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 TOWN CENTER PLZ STE A
MILL CREEK WV
26280-9752
US

IV. Provider business mailing address

PO BOX 247
MILL CREEK WV
26280-0247
US

V. Phone/Fax

Practice location:
  • Phone: 304-335-2050
  • Fax:
Mailing address:
  • Phone: 304-335-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102206565
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2462
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: