=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255403002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APPALACHIAN HIGHWAY MEDICAL & SURGICAL CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 01/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | APPALACHIAN HWY, RT. 10 EAST PINEVILLE
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24874-1274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-732-9045
-----------------------------------------------------
Fax | 304-732-9055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | APPALACHIAN HIGHWAY RT. 10 EAST PINEVILLE
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24874-1274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-732-9045
-----------------------------------------------------
Fax | 304-732-9055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. DOMINADOR YTI LAO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 304-732-9045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 12700
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------