Provider Demographics
NPI:1952907453
Name:DECARLO, ANTHONY J JR
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:DECARLO
Suffix:JR
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 1:248 BURGESS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-8143
Mailing Address - Country:US
Mailing Address - Phone:304-932-6743
Mailing Address - Fax:304-471-2488
Practice Address - Street 1:4510 PENNSYLVANIA AVE STE C
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4835
Practice Address - Country:US
Practice Address - Phone:304-965-9081
Practice Address - Fax:304-346-1860
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV48239163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse