Healthcare Provider Details

I. General information

NPI: 1750579066
Provider Name (Legal Business Name): GRANT COUNTY BOARD OF EDUCATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 JEFFERSON AVE
PETERSBURG WV
26847-1628
US

IV. Provider business mailing address

109 S. COLLEGE ST. RESA VIII
MARTINSBURG WV
25401
US

V. Phone/Fax

Practice location:
  • Phone: 304-257-1011
  • Fax: 304-267-3599
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: MS. THERESA A. STEWART
Title or Position: MEDICAID COORDINATOR
Credential:
Phone: 304-267-3595