Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2025-06-11
- Last updated
- 2025-06-11
Specialties
Licenses
The registry row did not include a license.
Location
- Practice location
- 650 WISTERIA LANE
- City
- OLD FIELDS WV
- Postal code
- 26845
- Phone
- 304-703-2062
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.