Healthcare Provider Details

I. General information

NPI: 1487604120
Provider Name (Legal Business Name): ADRIENNE VACCA MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 GRAND CENTRAL AVE SUITE 101
VIENNA WV
26105-1079
US

IV. Provider business mailing address

1500 GRAND CENTRAL AVE SUITE 101
VIENNA WV
26105-1079
US

V. Phone/Fax

Practice location:
  • Phone: 304-295-3060
  • Fax: 304-295-3068
Mailing address:
  • Phone: 304-295-3060
  • Fax: 304-295-3068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10914
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002475
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: