=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477953297
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISSA QUIROZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2014
-----------------------------------------------------
Last Update Date | 04/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 NATIONAL RD STE 100
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-6560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-230-5601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 36TH ST STE 100
-----------------------------------------------------
City | PARKERSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26101-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-917-3660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT004378
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------