Healthcare Provider Details

I. General information

NPI: 1700055365
Provider Name (Legal Business Name): GRANT COUNTY BOARD OF EDUCATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 JEFFERSON AVENUE GRANT COUNTY BOARD OF EDUCATION
PETERSBURG WV
26847
US

IV. Provider business mailing address

109 SOUTH COLLEGE STREET RESA VIII
MARTINSBURG WV
25401
US

V. Phone/Fax

Practice location:
  • Phone: 304-267-3595
  • Fax: 304-267-3595
Mailing address:
  • Phone: 304-267-3595
  • Fax: 304-267-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateWV

VIII. Authorized Official

Name: MRS. THERESA A STEWART
Title or Position: MEDICAID COORDINATOR
Credential:
Phone: 304-267-3595