Provider Demographics
NPI:1376816629
Name:DR. MICHAEL R. CONDARAS DCCC
Entity Type:Organization
Organization Name:DR. MICHAEL R. CONDARAS DCCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONDARAS
Authorized Official - Suffix:
Authorized Official - Credentials:DCCC
Authorized Official - Phone:304-342-3323
Mailing Address - Street 1:1202 VIRGINIA ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2909
Mailing Address - Country:US
Mailing Address - Phone:304-342-3323
Mailing Address - Fax:304-342-3357
Practice Address - Street 1:1202 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2909
Practice Address - Country:US
Practice Address - Phone:304-342-3323
Practice Address - Fax:304-342-3357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV161111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0131291000Medicaid
WVCO 0383813OtherMEDICARE ID- TYPE UNSPECIFIED
WV0131291000Medicaid