Healthcare Provider Details

I. General information

NPI: 1710231170
Provider Name (Legal Business Name): WVU URGENT CARE LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 EAST FOURTH AVENUE SUITE B
RANSON WV
25438
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 304-725-2273
  • Fax: 304-725-9843
Mailing address:
  • Phone: 304-285-7100
  • Fax: 304-285-7126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number51D2047840
License Number StateWV

VIII. Authorized Official

Name: ANDREA RUMBLE
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 304-285-7101