Provider Demographics
NPI:1700507324
Name:PRINCE, MICHAEL RAY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:PRINCE
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 1:219 JOSEPHINE AVE APT 21
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1372
Mailing Address - Country:US
Mailing Address - Phone:304-928-5843
Mailing Address - Fax:
Practice Address - Street 1:219 JOSEPHINE AVE APT 21
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1372
Practice Address - Country:US
Practice Address - Phone:304-928-5843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant