=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063663896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2008
-----------------------------------------------------
Last Update Date | 10/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 STATION PLACE WAY
-----------------------------------------------------
City | HURRICANE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25526-8747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-757-7788
-----------------------------------------------------
Fax | 304-201-1140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 STATION PLACE WAY
-----------------------------------------------------
City | HURRICANE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25526-8747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-757-7788
-----------------------------------------------------
Fax | 304-201-1140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SEAN C. DI CRISTOFARO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-757-7788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | DP00454495
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 19679
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------