Provider Demographics
NPI:1417976382
Name:INTEGRATED HEALTH CARE PROVIDERS, INC
Entity Type:Organization
Organization Name:INTEGRATED HEALTH CARE PROVIDERS, INC
Other - Org Name:SPORTS MEDICINE & REHAB CENTER CROSS LANES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MBA
Authorized Official - Phone:304-388-7783
Mailing Address - Street 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:130 GOFF MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1419
Practice Address - Country:US
Practice Address - Phone:304-388-7055
Practice Address - Fax:304-388-7058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006518Medicaid
WV3810006518Medicaid
1248180006Medicare PIN
1248180006Medicare NSC