=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457084840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN WEST VIRGINIA CENTER FOR INDEPENDENT LIVING INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2022
-----------------------------------------------------
Last Update Date | 07/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 E BROCKWAY AVE # 3
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-0106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-296-6091
-----------------------------------------------------
Fax | 304-292-5217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 E BROCKWAY AVE # 3
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-0106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-296-6091
-----------------------------------------------------
Fax | 304-292-5217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. ANNETTA JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-296-6091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------