=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013456094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW BEGINNINGS DRUG TREATMENT CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2017
-----------------------------------------------------
Last Update Date | 02/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4855 MACCORKLE AVE SW
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-720-4444
-----------------------------------------------------
Fax | 646-839-2999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4855 MACCORKLE AVE SW
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-720-4444
-----------------------------------------------------
Fax | 646-839-2999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM MUCKLOW
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 304-720-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 2017-008
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------