Healthcare Provider Details

I. General information

NPI: 1003218397
Provider Name (Legal Business Name): MKSC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WHARTON CIR STE 130
TRIADELPHIA WV
26059-1539
US

IV. Provider business mailing address

300 WHARTON CIR STE 130
TRIADELPHIA WV
26059-1539
US

V. Phone/Fax

Practice location:
  • Phone: 304-242-8042
  • Fax: 304-242-8962
Mailing address:
  • Phone: 304-242-8042
  • Fax: 304-242-8962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number19164
License Number StateWV

VIII. Authorized Official

Name: DR. DANTE A MARRA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 304-242-8042