Healthcare Provider Details

I. General information

NPI: 1740685932
Provider Name (Legal Business Name): PEDIATRIC LUNG & ASTHMA CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 03/07/2023
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1284 SUNCREST TOWN CENTRE DR
MORGANTOWN WV
26505-1828
US

IV. Provider business mailing address

1284 SUNCREST TOWNE CENTRE DR.
MORGANTOWN WV
26505-1828
US

V. Phone/Fax

Practice location:
  • Phone: 304-284-8999
  • Fax: 304-284-9777
Mailing address:
  • Phone: 304-284-8999
  • Fax: 304-284-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number22524
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. TALIA B SOTOMAYOR VALENZUELA
Title or Position: PEDIATRIC PULMONOLOGIST/OWNER
Credential: M.D.
Phone: 304-284-8999