Healthcare Provider Details

I. General information

NPI: 1902045776
Provider Name (Legal Business Name): INTEGRATED HEALTH CARE PROVIDERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 RHL BOULEVARD SUITE 3, SOUTHRIDGE HEALTH PLUS
SOUTH CHARLESTON WV
25309
US

IV. Provider business mailing address

415 MORRIS ST SUITE 304
CHARLESTON WV
25301-1842
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7010
  • Fax: 304-388-7015
Mailing address:
  • Phone: 304-388-7784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number51D1088105
License Number StateWV

VIII. Authorized Official

Name: JEFFREY H. GOODE
Title or Position: PRESIDENT
Credential:
Phone: 304-388-7784