Healthcare Provider Details

I. General information

NPI: 1639665912
Provider Name (Legal Business Name): DAMOUS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 LEE AVE
NITRO WV
25143
US

IV. Provider business mailing address

218 D ST
SOUTH CHARLESTON WV
25303-3104
US

V. Phone/Fax

Practice location:
  • Phone: 304-201-2095
  • Fax:
Mailing address:
  • Phone: 304-720-3835
  • Fax: 304-720-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE MICHAEL DAMOUS
Title or Position: OWNER
Credential: MA
Phone: 304-720-3835