Provider Demographics
NPI:1619951977
Name:ST OF WV DIV OF REHABILITATION SERVICES
Entity Type:Organization
Organization Name:ST OF WV DIV OF REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR, CENTER ADMINIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-766-4767
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:INSTITUTE
Mailing Address - State:WV
Mailing Address - Zip Code:25112-1004
Mailing Address - Country:US
Mailing Address - Phone:304-766-4848
Mailing Address - Fax:304-766-4937
Practice Address - Street 1:BARRON DRIVE
Practice Address - Street 2:
Practice Address - City:INSTITUTE
Practice Address - State:WV
Practice Address - Zip Code:25112-1004
Practice Address - Country:US
Practice Address - Phone:304-766-4848
Practice Address - Fax:304-766-4937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVNA GOV'T OWNED261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV=========OtherCOMMERCIAL INSURANCES