=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174401764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CJS INDUSTRIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2025
-----------------------------------------------------
Last Update Date | 08/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1414 MARTHA RD
-----------------------------------------------------
City | BARBOURSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25504-7121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-412-8455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1414 MARTHA RD
-----------------------------------------------------
City | BARBOURSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25504-7121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-412-8455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. CHARLES SMITH
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 304-412-8455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------