Healthcare Provider Details

I. General information

NPI: 1003931429
Provider Name (Legal Business Name): INTEGRATED HEALTH CARE PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HOSPITAL DR
SPENCER WV
25276-1049
US

IV. Provider business mailing address

415 MORRIS ST
CHARLESTON WV
25301-1842
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7782
  • Fax: 304-388-7788
Mailing address:
  • Phone: 304-388-7782
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF GOODE
Title or Position: EXEC DIRECTOR
Credential: PT, MBA
Phone: 304-388-7782