Healthcare Provider Details

I. General information

NPI: 1730353954
Provider Name (Legal Business Name): DODDRIDGE CO SENIOR CITIZEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W MAIN ST
WEST UNION WV
26456-1127
US

IV. Provider business mailing address

403 W MAIN ST
WEST UNION WV
26456-1127
US

V. Phone/Fax

Practice location:
  • Phone: 304-873-2061
  • Fax: 304-873-1769
Mailing address:
  • Phone: 314-873-2061
  • Fax: 304-873-1769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: MR. MARVIN E TRAVIS
Title or Position: DIRECTOR
Credential:
Phone: 304-873-2061