=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346434867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL MEDICAL REHABILITATION INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2007
-----------------------------------------------------
Last Update Date | 01/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 460 MYLAN PARK LN
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-2281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-983-7766
-----------------------------------------------------
Fax | 304-983-7768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 460 MYLAN PARK LN
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-2281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-983-7766
-----------------------------------------------------
Fax | 304-983-7768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. J DAVID LYNCH JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 304-983-7766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT002617
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA001299
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 1999 0357
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | WV16960
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------