Healthcare Provider Details

I. General information

NPI: 1417249459
Provider Name (Legal Business Name): ST. ALBANS INTEGRATIVE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAIN ST
SAINT ALBANS WV
25177-2802
US

IV. Provider business mailing address

552 BOX
ST. ALBANS WV
25177
US

V. Phone/Fax

Practice location:
  • Phone: 304-201-3600
  • Fax: 304-201-2368
Mailing address:
  • Phone: 304-201-3600
  • Fax: 304-201-2368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number18688
License Number StateWV

VIII. Authorized Official

Name: MR. RUDOLPH MICHAEL KEVAK JR.
Title or Position: OWNER
Credential: M.D.
Phone: 304-201-3600