Provider Demographics
NPI:1346401734
Name:SHELTERED WORKSHOP OF NICHOLAS COUNTY
Entity Type:Organization
Organization Name:SHELTERED WORKSHOP OF NICHOLAS COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-742-6202
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:CRAIGSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26205-0730
Mailing Address - Country:US
Mailing Address - Phone:304-742-6202
Mailing Address - Fax:304-742-6280
Practice Address - Street 1:16810 WEBSTER RD.
Practice Address - Street 2:PO DRAWER 730
Practice Address - City:CRAIGSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26205-0730
Practice Address - Country:US
Practice Address - Phone:304-742-6202
Practice Address - Fax:304-742-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1036-8190251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005379000Medicaid