MEDICARE: W VA ORTHOTIC & PROSTHETIC CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	269736	OTHER		MAMSI
3	1040111	OTHER	WV	W/COMP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154327823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W VA ORTHOTIC & PROSTHETIC CENTER, INC.

Provider Business Mailing Address
First Line	:	64 BROOKSHIRE LN
Second Line	:
City	:	BECKLEY
State	:	WV
Zip	:	25801-6765
Country	:	US
Telephone Number	:	304-256-8351
Fax Number	:	304-256-8387

Provider Business Practice Location Address
First Line	:	64 BROOKSHIRE LN
Second Line	:
City	:	BECKLEY
State	:	WV
Zip	:	25801-6765
Country	:	US
Telephone Number	:	304-256-8351
Fax Number	:	304-256-8387

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MRS. AUDREY E LETT
Credential	:
Telephone Number	:	304-256-8351

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	08/22/2020

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