Provider Demographics
NPI:1093220303
Name:WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC
Entity Type:Organization
Organization Name:WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC
Other - Org Name:ROBERT C. BYRD CLINIC - RUPERT
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-647-1211
Mailing Address - Street 1:1464 JEFFERSON ST N
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1380
Mailing Address - Country:US
Mailing Address - Phone:304-645-3220
Mailing Address - Fax:304-793-2491
Practice Address - Street 1:356 NICHOLAS STREET
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:WV
Practice Address - Zip Code:25984
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:304-645-4103
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-08
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
WV36604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty