=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063692333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WV THERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2007
-----------------------------------------------------
Last Update Date | 03/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 W MAIN ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-1751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-842-9887
-----------------------------------------------------
Fax | 304-842-9888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 BENEDUM DR
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-1503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-842-9887
-----------------------------------------------------
Fax | 304-842-9888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. GREGORY ALAN HAYES
-----------------------------------------------------
Credential | PTA
-----------------------------------------------------
Telephone | 304-842-9887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0420593001
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------