Provider Demographics
NPI:1750497145
Name:FOUR SEASONS FAMILY PRACTICE
Entity Type:Organization
Organization Name:FOUR SEASONS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOHUIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-431-7100
Mailing Address - Street 1:PO BOX 1050
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-1050
Mailing Address - Country:US
Mailing Address - Phone:304-431-7100
Mailing Address - Fax:304-431-7112
Practice Address - Street 1:904 HARRISON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3011
Practice Address - Country:US
Practice Address - Phone:304-431-7100
Practice Address - Fax:304-431-7112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0053383000Medicaid
WVF09306901Medicare ID - Type Unspecified