Provider Demographics
NPI:1780898072
Name:MEDABOLIX, INC.
Entity type:Organization
Organization Name:MEDABOLIX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STICKLER
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:304-347-4313
Mailing Address - Street 1:600 TRACY WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1262
Mailing Address - Country:US
Mailing Address - Phone:304-347-4313
Mailing Address - Fax:304-347-4316
Practice Address - Street 1:600 TRACY WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1262
Practice Address - Country:US
Practice Address - Phone:304-347-4313
Practice Address - Fax:304-347-4316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty