Provider Demographics
NPI:1891013108
Name:INTEGRATED HEALTH CARE PROVIDERS, INC.
Entity Type:Organization
Organization Name:INTEGRATED HEALTH CARE PROVIDERS, INC.
Other - Org Name:UROLOGY CENTER MEMORIAL LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:304-388-7782
Mailing Address - Street 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:3100 MACCORKLE AVE SE
Practice Address - Street 2:SUITE 408
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-388-5280
Practice Address - Fax:304-388-5291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D2006880291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV51D2006880OtherCLIA NUMBER