Provider Demographics
NPI:1619141322
Name:DODDRIDGE CO SENIOR CITIZENS
Entity Type:Organization
Organization Name:DODDRIDGE CO SENIOR CITIZENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-873-2061
Mailing Address - Street 1:403 WEST UNION
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:WV
Mailing Address - Zip Code:26456
Mailing Address - Country:US
Mailing Address - Phone:304-873-2061
Mailing Address - Fax:304-873-1769
Practice Address - Street 1:403 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:WV
Practice Address - Zip Code:26456-1127
Practice Address - Country:US
Practice Address - Phone:304-873-2061
Practice Address - Fax:304-873-1769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030953001Medicaid