Provider Demographics
NPI:1114530813
Name:COLLINS, CLINT W
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:W
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BOONE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-1905
Mailing Address - Country:US
Mailing Address - Phone:304-421-2289
Mailing Address - Fax:
Practice Address - Street 1:114 BOONE ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-1905
Practice Address - Country:US
Practice Address - Phone:304-421-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant