Provider Demographics
NPI:1578626081
Name:WVVDHHR DIV. SURVEILLANCE & DISEASE CONTROL
Entity Type:Organization
Organization Name:WVVDHHR DIV. SURVEILLANCE & DISEASE CONTROL
Other - Org Name:WV STATE HEMOPHILIA PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:DIVISION DIRECTYOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HADDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-558-5358
Mailing Address - Street 1:350 CAPITOL ST
Mailing Address - Street 2:ROOM 125
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1757
Mailing Address - Country:US
Mailing Address - Phone:304-558-5358
Mailing Address - Fax:304-558-6335
Practice Address - Street 1:350 CAPITOL ST
Practice Address - Street 2:ROOM 125
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1757
Practice Address - Country:US
Practice Address - Phone:304-558-5358
Practice Address - Fax:304-558-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVNOT REQUIRED251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0017402000Medicaid