Provider Demographics
NPI:1407258148
Name:POLING, RICK
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:POLING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26147-0619
Mailing Address - Country:US
Mailing Address - Phone:304-354-7017
Mailing Address - Fax:304-354-6859
Practice Address - Street 1:105 MARKET ST.
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26147
Practice Address - Country:US
Practice Address - Phone:304-354-7017
Practice Address - Fax:304-354-6859
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103594633747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030566000Medicaid
WV0030566001Medicaid