=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992175889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BECKLEY V AMC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2015
-----------------------------------------------------
Last Update Date | 10/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 VETERANS AVE
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-6444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-229-8066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 KINGLET PL
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-229-8066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALS COORDINATOR
-----------------------------------------------------
Name | DONNA KENNEDA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-255-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QV0200X
-----------------------------------------------------
Taxonomy Name | VA Clinic/Center
-----------------------------------------------------
License Number | RP0007053
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------