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General NPI Number Information
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NPI Number | 1639412398
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Entity Type | Organization
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Legal Business Name | POTOMAC INTEGRATIVE HEALTH PLLC
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Dates
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Enumeration Date | 04/01/2013
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Last Update Date | 04/01/2013
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Provider Practice Location Address
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Address Line | 51 MADDEX SQUARE DRIVE
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City | SHEPHERDSTOWN
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State | WV
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Zip | 25443-4310
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Country | US
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Telephone | 304-876-2447
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1311 51 MADDEX SQUARE DRIVE
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City | SHEPHERDSTOWN
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State | WV
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Zip | 25443-1311
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DAVID DIDDEN
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Credential |
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Telephone | 304-876-2447
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 21679
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License Number State | WV
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