Provider Demographics
NPI:1639782220
Name:STUART, RAY ERVIN
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:ERVIN
Last Name:STUART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BROOKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-4937
Mailing Address - Country:US
Mailing Address - Phone:304-205-3955
Mailing Address - Fax:
Practice Address - Street 1:75 BROOKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4937
Practice Address - Country:US
Practice Address - Phone:304-205-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant