Provider Demographics
NPI:1770999120
Name:KRISTY M FERGUSON
Entity type:Organization
Organization Name:KRISTY M FERGUSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:304-743-8534
Mailing Address - Street 1:1109 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541
Mailing Address - Country:US
Mailing Address - Phone:304-743-8534
Mailing Address - Fax:
Practice Address - Street 1:1109 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541
Practice Address - Country:US
Practice Address - Phone:304-743-8534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2005-1681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty