Provider Demographics
NPI:1083171078
Name:PREMIUM MARTIAL ARTS WV LLC
Entity Type:Organization
Organization Name:PREMIUM MARTIAL ARTS WV LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/INSTRUCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-807-0251
Mailing Address - Street 1:602 CROSSROADS VLG
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-2054
Mailing Address - Country:US
Mailing Address - Phone:304-807-0251
Mailing Address - Fax:
Practice Address - Street 1:963 DUNBAR VILLAGE PLZ
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3137
Practice Address - Country:US
Practice Address - Phone:304-807-0251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services