=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497576417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVENTUS PREMIER HEALTHCARE - WEST VIRGINIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2024
-----------------------------------------------------
Last Update Date | 10/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 CAPITOL ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25301-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-743-2247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1431 DEPT 430
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28201-1431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-743-2247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRADLEY GOAD
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 855-743-2247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------