Provider Demographics
NPI:1750022463
Name:PACK, KRISTOPHER CALEB
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:CALEB
Last Name:PACK
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 1:1575 ARNOLD CT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2909
Mailing Address - Country:US
Mailing Address - Phone:304-673-9546
Mailing Address - Fax:
Practice Address - Street 1:100 ANGUS E PEYTON DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1600
Practice Address - Country:US
Practice Address - Phone:304-746-2088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV97394163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool