Basic Information
Provider Information | |||||||||
NPI: | 1760651483 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAYETTE COUNTY BOARD OF EDUCATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 404 OLD MAIN DR | ||||||||
Address2: |   | ||||||||
City: | SUMMERSVILLE | ||||||||
State: | WV | ||||||||
PostalCode: | 266511360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3048726440 | ||||||||
FaxNumber: | 3048726442 | ||||||||
Practice Location | |||||||||
Address1: | 111 FAYETTE AVE | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | WV | ||||||||
PostalCode: | 258401219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045741176 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2008 | ||||||||
LastUpdateDate: | 02/27/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RADER | ||||||||
AuthorizedOfficialFirstName: | BILLIE | ||||||||
AuthorizedOfficialMiddleName: | JEAN | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAID SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3048726440 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X |   | WV | Y |   | Agencies | Local Education Agency (LEA) |   |
No ID Information.