Provider Demographics
NPI:1154327823
Name:W VA ORTHOTIC & PROSTHETIC CENTER, INC.
Entity Type:Organization
Organization Name:W VA ORTHOTIC & PROSTHETIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-256-8351
Mailing Address - Street 1:64 BROOKSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6765
Mailing Address - Country:US
Mailing Address - Phone:304-256-8351
Mailing Address - Fax:304-256-8387
Practice Address - Street 1:64 BROOKSHIRE LN
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6765
Practice Address - Country:US
Practice Address - Phone:304-256-8351
Practice Address - Fax:304-256-8387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0147818001Medicaid
269736OtherMAMSI
WV1040111OtherW/COMP
WV0147818000Medicaid
WV=========OtherUMWA
WV0147818000Medicaid
269736OtherMAMSI
WV0147818001Medicaid