Provider Demographics
NPI:1225817802
Name:GREENE SKIN AND WELLNESS
Entity Type:Organization
Organization Name:GREENE SKIN AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-688-7027
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:DAVIN
Mailing Address - State:WV
Mailing Address - Zip Code:25617-0445
Mailing Address - Country:US
Mailing Address - Phone:304-310-2261
Mailing Address - Fax:304-310-2262
Practice Address - Street 1:40 SHAE AVE STE A
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508-9805
Practice Address - Country:US
Practice Address - Phone:304-310-2261
Practice Address - Fax:304-310-2262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty