=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326382821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONY DRUG & WELLNESS CENTER DSME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2012
-----------------------------------------------------
Last Update Date | 11/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 ROBERT C BYRD DR
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-5238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-252-5305
-----------------------------------------------------
Fax | 304-253-4281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2810 ROBERT C BYRD DR
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-5238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-252-5305
-----------------------------------------------------
Fax | 304-253-4281
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM COORDINATOR
-----------------------------------------------------
Name | ARNOLD VAUGHN
-----------------------------------------------------
Credential | R.D., L.D., C.D.E.
-----------------------------------------------------
Telephone | 304-252-5305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------