Provider Demographics
NPI:1053455113
Name:WETZEL COUNTY COA
Entity Type:Organization
Organization Name:WETZEL COUNTY COA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTER NURSE
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:HALL
Authorized Official - Last Name:CULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTER NURSE
Authorized Official - Phone:304-455-3220
Mailing Address - Street 1:145 PADUCAH DR
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-2709
Mailing Address - Country:US
Mailing Address - Phone:304-455-3044
Mailing Address - Fax:304-455-0280
Practice Address - Street 1:145 PADUCAH DR
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2709
Practice Address - Country:US
Practice Address - Phone:304-455-3044
Practice Address - Fax:304-455-0280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10363962253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030804001Medicaid
WV0030804002Medicaid
WV0030804000Medicaid