Healthcare Provider Details

I. General information

NPI: 1346434867
Provider Name (Legal Business Name): PROFESSIONAL MEDICAL REHABILITATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 MYLAN PARK LN
MORGANTOWN WV
26501-2281
US

IV. Provider business mailing address

460 MYLAN PARK LN
MORGANTOWN WV
26501-2281
US

V. Phone/Fax

Practice location:
  • Phone: 304-983-7766
  • Fax: 304-983-7768
Mailing address:
  • Phone: 304-983-7766
  • Fax: 304-983-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002617
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA001299
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1999 0357
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberWV16960
License Number StateWV

VIII. Authorized Official

Name: DR. J DAVID LYNCH JR.
Title or Position: CEO
Credential: M.D.
Phone: 304-983-7766