Provider Demographics
NPI:1114139722
Name:EXPRESS CARE CLINIC L.L.C.
Entity Type:Organization
Organization Name:EXPRESS CARE CLINIC L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:304-255-5533
Mailing Address - Street 1:1455 ROBERT C BYRD DR
Mailing Address - Street 2:P.O. BOX 755
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25827-9441
Mailing Address - Country:US
Mailing Address - Phone:304-255-5533
Mailing Address - Fax:304-929-5533
Practice Address - Street 1:1455 ROBERT C BYRD DR
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827-9441
Practice Address - Country:US
Practice Address - Phone:304-255-5533
Practice Address - Fax:304-929-5533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV48923363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7104152000Medicaid
WVP80274Medicare UPIN
WVNP12421Medicare ID - Type Unspecified