Healthcare Provider Details

I. General information

NPI: 1487284451
Provider Name (Legal Business Name): COAL RIVER PRIMARY CARE AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2020
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 FORK CREEK RD
NELLIS WV
25142-9737
US

IV. Provider business mailing address

62 FORK CREEK RD
NELLIS WV
25142-9737
US

V. Phone/Fax

Practice location:
  • Phone: 304-833-0815
  • Fax: 304-833-0030
Mailing address:
  • Phone: 304-833-0815
  • Fax: 304-833-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: REBECCA RUBY BARKER
Title or Position: SOLE OWNER; FNP-BC
Credential: FNP
Phone: 304-833-0815