Basic Information
Provider Information | |||||||||
NPI: | 1205988110 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OHIO VALLEY MEDICAL QUICKCARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 417 GRAND PARK DR | ||||||||
Address2: | SUITE 103 | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261054049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044852700 | ||||||||
FaxNumber: | 3044850481 | ||||||||
Practice Location | |||||||||
Address1: | 517 36TH ST | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261011006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044851044 | ||||||||
FaxNumber: | 3044221861 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JURADO | ||||||||
AuthorizedOfficialFirstName: | JOHNNY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3044852700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 291U00000X | WV | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 0019701003 | 05 | WV |   | MEDICAID | 2208891 | 05 | OH |   | MEDICAID | 0019701002 | 05 | OH |   | MEDICAID | 2242433 | 05 | WV |   | MEDICAID |