=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558447805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LITTLE BEAVER FAMILY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2006
-----------------------------------------------------
Last Update Date | 10/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16130 WEBSTER RD.
-----------------------------------------------------
City | CRAIGSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26205-1728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-742-3570
-----------------------------------------------------
Fax | 304-742-3572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1728
-----------------------------------------------------
City | CRAIGSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26205-1728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-742-3570
-----------------------------------------------------
Fax | 304-742-3572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | CHERYL L WHITE
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 304-742-3570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 52802
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------