Healthcare Provider Details

I. General information

NPI: 1730438797
Provider Name (Legal Business Name): SEAN LEIBROCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 STADIUM DR
MORGANTOWN WV
26506-7911
US

IV. Provider business mailing address

101 STADIUM DR
MORGANTOWN WV
26506-7911
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4850
  • Fax: 304-598-4871
Mailing address:
  • Phone: 304-598-4850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: