Healthcare Provider Details

I. General information

NPI: 1265954895
Provider Name (Legal Business Name): IDEAL OPTION, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 PINEVIEW DR
MORGANTOWN WV
26505-0482
US

IV. Provider business mailing address

8656 W GAGE BLVD ST 301B
KENNEWICK WA
99336-7145
US

V. Phone/Fax

Practice location:
  • Phone: 877-522-1275
  • Fax: 509-491-3031
Mailing address:
  • Phone: 509-222-1275
  • Fax: 509-491-3031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRIAN JEFFERSON DAWSON
Title or Position: CMO
Credential: MD
Phone: 509-222-1275