Provider Demographics
NPI:1740685932
Name:PEDIATRIC LUNG & ASTHMA CENTER, PLLC
Entity type:Organization
Organization Name:PEDIATRIC LUNG & ASTHMA CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PULMONOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TALIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:SOTOMAYOR VALENZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-284-8999
Mailing Address - Street 1:1284 SUNCREST TOWNE CENTRE DR.
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1828
Mailing Address - Country:US
Mailing Address - Phone:304-284-8999
Mailing Address - Fax:304-284-9777
Practice Address - Street 1:1284 SUNCREST TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1828
Practice Address - Country:US
Practice Address - Phone:304-284-8999
Practice Address - Fax:304-284-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22524174400000X
174400000X, 2080P0214X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV162849OtherUPIN
WY3910006278Medicaid
WY3910006278Medicaid