Provider Demographics
NPI:1841684271
Name:PACAK, THOMAS (CPO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PACAK
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4112
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26504-4112
Mailing Address - Country:US
Mailing Address - Phone:304-241-4094
Mailing Address - Fax:304-381-2041
Practice Address - Street 1:1137 VAN VOORHIS RD
Practice Address - Street 2:SUITE 15
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3453
Practice Address - Country:US
Practice Address - Phone:304-241-4094
Practice Address - Fax:304-381-2041
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
PAOH000177224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7410930001Medicare NSC