Provider Demographics
NPI:1225227549
Name:CHILDERS, ALICE
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635-1023
Mailing Address - Country:US
Mailing Address - Phone:304-583-6541
Mailing Address - Fax:304-583-6018
Practice Address - Street 1:600 E MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-1023
Practice Address - Country:US
Practice Address - Phone:304-583-6541
Practice Address - Fax:304-583-6018
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0577247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist