Healthcare Provider Details

I. General information

NPI: 1053604728
Provider Name (Legal Business Name): ELEONORA I GREY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 01/27/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 RED OAKS SHOPPING CTR
RONCEVERTE WV
24970-1364
US

IV. Provider business mailing address

320 RED OAKS SHOPPING CTR
RONCEVERTE WV
24970-1364
US

V. Phone/Fax

Practice location:
  • Phone: 304-689-4488
  • Fax: 304-927-8198
Mailing address:
  • Phone: 304-689-4488
  • Fax: 866-920-6674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2651
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2651
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: