Provider Demographics
NPI:1336243880
Name:MEDCARE THERAPY CENTER
Entity type:Organization
Organization Name:MEDCARE THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:304-776-5031
Mailing Address - Street 1:314 GOFF MTN. RD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313
Mailing Address - Country:US
Mailing Address - Phone:304-776-5031
Mailing Address - Fax:304-204-6332
Practice Address - Street 1:314 GOFF MTN RD
Practice Address - Street 2:SUITE 13
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313
Practice Address - Country:US
Practice Address - Phone:304-776-5031
Practice Address - Fax:304-204-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 235Z00000X
WV002137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV730106300Medicaid
WV001705831OtherMOUNTIAN STATE BC/BS
WV0206908000Medicaid
WV4052263Medicare PIN
WV730106300Medicaid
WV9331781Medicare PIN
BR4052263Medicare Oscar/Certification