=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083171078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIUM MARTIAL ARTS WV LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2019
-----------------------------------------------------
Last Update Date | 02/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 963 DUNBAR VILLAGE PLZ
-----------------------------------------------------
City | DUNBAR
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25064-3137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-807-0251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 602 CROSSROADS VLG
-----------------------------------------------------
City | NITRO
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25143-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-807-0251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/INSTRUCTOR
-----------------------------------------------------
Name | JESSICA LYNN MADDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-807-0251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------