Provider Demographics
NPI:1669724928
Name:VALLEY REGIONAL ENTERPRISES, INC
Entity type:Organization
Organization Name:VALLEY REGIONAL ENTERPRISES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIVISION CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-536-4310
Mailing Address - Street 1:97 ADMINISTRATIVE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-6378
Mailing Address - Country:US
Mailing Address - Phone:304-350-3200
Mailing Address - Fax:304-350-3201
Practice Address - Street 1:97 ADMINISTRATIVE DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-6378
Practice Address - Country:US
Practice Address - Phone:304-350-3200
Practice Address - Fax:304-350-3201
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALLEY REGIONAL ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057756261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care