=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700285764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUTNAM COUNTY AGING PROGRAM, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2014
-----------------------------------------------------
Last Update Date | 08/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2558 WINFIELD RD
-----------------------------------------------------
City | SAINT ALBANS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25177-7804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-755-2385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2558 WINFIELD RD
-----------------------------------------------------
City | SAINT ALBANS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25177-7804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-755-2385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FISCAL OFFICER
-----------------------------------------------------
Name | DEBRA DOSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-755-2385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------