Healthcare Provider Details

I. General information

NPI: 1154693653
Provider Name (Legal Business Name): REKLAW DIVERSIFIED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 12TH STREET EXT
PRINCETON WV
24740-2352
US

IV. Provider business mailing address

120 12TH STREET EXT
PRINCETON WV
24740-2352
US

V. Phone/Fax

Practice location:
  • Phone: 304-487-8000
  • Fax: 304-487-5666
Mailing address:
  • Phone: 304-487-8000
  • Fax: 304-487-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number24684
License Number StateWV

VIII. Authorized Official

Name: DR. ROBERT WALKER
Title or Position: CEO
Credential: MD
Phone: 312-371-0039