Healthcare Provider Details

I. General information

NPI: 1770243156
Provider Name (Legal Business Name): JEFFERSON BAYLOR HAUGHT STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W 4TH ST
WILLIAMSTOWN WV
26187-1107
US

IV. Provider business mailing address

406 W 4TH ST
WILLIAMSTOWN WV
26187-1107
US

V. Phone/Fax

Practice location:
  • Phone: 304-580-9008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: