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General NPI Number Information
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NPI Number | 1063212835
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Entity Type | Individual
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Provider Name | JACK SHOMO
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Gender | Male
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Dates
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Enumeration Date | 03/19/2025
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Last Update Date | 03/19/2025
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Provider Practice Location Address
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Address Line | 1123 S DAVIS AVE
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City | ELKINS
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State | WV
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Zip | 26241-3529
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Country | US
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Telephone | 681-378-3908
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Fax |
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Provider Business Mailing Address
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Address Line | 1008 S DAVIS AVE
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City | ELKINS
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State | WV
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Zip | 26241-3528
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Country | US
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Telephone | 304-621-5223
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Fax | 304-621-5223
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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