Healthcare Provider Details

I. General information

NPI: 1629294673
Provider Name (Legal Business Name): MID-VALLEY HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N MAIN ST
NEW MARTINSVILLE WV
26155-1215
US

IV. Provider business mailing address

PO BOX 6400
WHEELING WV
26003-0801
US

V. Phone/Fax

Practice location:
  • Phone: 304-234-3500
  • Fax: 304-234-3511
Mailing address:
  • Phone: 304-234-3500
  • Fax: 304-234-3511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number387
License Number StateWV

VIII. Authorized Official

Name: MARK A GAMES
Title or Position: DIRECTOR
Credential:
Phone: 304-234-3500