Healthcare Provider Details

I. General information

NPI: 1467668368
Provider Name (Legal Business Name): TERESA L. WHITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRO MEDICAL REHAB 460 MYLAN PARK LANE
MORGANTOWN WV
26501
US

IV. Provider business mailing address

PRO MEDICAL REHAB 460 MYLAN PARK LANE
MORGANTOWN WV
26501
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 TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19990357
License Number StateWV

VIII. Authorized Official

Name: MR. JOHN DAVID LYNCH
Title or Position: OWNERPROVIDER
Credential: M.D.
Phone: 304-983-7766