Provider Demographics
NPI:1669538732
Name:ETERNITY, INC
Entity type:Organization
Organization Name:ETERNITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICEPRESIDENT, SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:RIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:304-291-5964
Mailing Address - Street 1:112 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-6584
Mailing Address - Country:US
Mailing Address - Phone:304-291-5964
Mailing Address - Fax:
Practice Address - Street 1:112 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-6584
Practice Address - Country:US
Practice Address - Phone:304-291-5964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-30
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV529101YM0800X
WVDP004542991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SW09442OtherPTAN
SW09442OtherPTAN