Healthcare Provider Details

I. General information

NPI: 1487239034
Provider Name (Legal Business Name): TIMOTHY WYATT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 ROCK ROAD
MONTCALM WV
24737
US

IV. Provider business mailing address

PO BOX 492
MONTCALM WV
24737-0492
US

V. Phone/Fax

Practice location:
  • Phone: 304-960-5583
  • Fax:
Mailing address:
  • Phone: 304-960-5583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: