=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124806831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONARCH WOUND CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2023
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 FORT PIERPONT DR STE 105
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26508-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-241-7667
-----------------------------------------------------
Fax | 304-241-7568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 FORT PIERPONT DR STE 105
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26508-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-241-7667
-----------------------------------------------------
Fax | 304-241-7568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PROVIDER
-----------------------------------------------------
Name | JACQUELINE J GAY
-----------------------------------------------------
Credential | DPT, CWS
-----------------------------------------------------
Telephone | 304-241-7667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------