Provider Demographics
NPI:1558371328
Name:WEST VIRGINIA PHYSICAL THERAPY & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:WEST VIRGINIA PHYSICAL THERAPY & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO. OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEORGEANN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-645-2525
Mailing Address - Street 1:717 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9506
Mailing Address - Country:US
Mailing Address - Phone:304-645-2525
Mailing Address - Fax:304-645-2820
Practice Address - Street 1:717 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9506
Practice Address - Country:US
Practice Address - Phone:304-645-2525
Practice Address - Fax:304-645-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV71364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004938Medicaid
WV3810004938Medicaid