=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184700957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL WEST VIRGINIA PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 BROAD ST
-----------------------------------------------------
City | SUMMERSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26651-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-872-2735
-----------------------------------------------------
Fax | 304-872-9416
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 BROAD ST
-----------------------------------------------------
City | SUMMERSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26651-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-872-2735
-----------------------------------------------------
Fax | 304-872-9416
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATHY O. BUCKS
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 304-872-2735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 000461
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------