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General NPI Number Information
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NPI Number | 1629004221
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Entity Type | Organization
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Legal Business Name | COLLABORATIVE GERIATRICS, INC.
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Dates
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Enumeration Date | 06/24/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 414 MAHOGANYWOOD DR
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City | MILTON
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State | WV
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Zip | 25541-1181
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Country | US
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Telephone | 304-743-8007
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Fax | 304-743-1704
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Provider Business Mailing Address
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Address Line | PO BOX 979
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City | CULLODEN
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State | WV
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Zip | 25510-0979
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Country | US
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Telephone | 304-743-8007
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Fax | 304-743-1704
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Authorized Official
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Title or Position | ADMINISTRATIVE ASSISTANT
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Name | COURTNEY BROOKE TAYLOR
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Credential |
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Telephone | 304-743-8007
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 21327
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 1601
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License Number State | WV
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Taxonomy #3
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 20005
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License Number State | WV
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Taxonomy #4
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 14713
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License Number State | WV
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