Provider Demographics
NPI:1003072398
Name:DR. RICK L HOUDERSHELDT, INC
Entity Type:Organization
Organization Name:DR. RICK L HOUDERSHELDT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOUDERSHELDT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-757-6990
Mailing Address - Street 1:3705 TEAYS VALLEY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8757
Mailing Address - Country:US
Mailing Address - Phone:304-757-6990
Mailing Address - Fax:304-757-0911
Practice Address - Street 1:3705 TEAYS VALLEY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8757
Practice Address - Country:US
Practice Address - Phone:304-757-6990
Practice Address - Fax:304-757-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV789261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0084490000Medicaid
WV0084490000Medicaid
WV0546842Medicare PIN