Provider Demographics
NPI:1366900532
Name:ADCOCK, CAISIE
Entity type:Individual
Prefix:
First Name:CAISIE
Middle Name:
Last Name:ADCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GIVEN
Mailing Address - State:WV
Mailing Address - Zip Code:25245-8067
Mailing Address - Country:US
Mailing Address - Phone:304-531-5471
Mailing Address - Fax:
Practice Address - Street 1:113 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:GIVEN
Practice Address - State:WV
Practice Address - Zip Code:25245-8067
Practice Address - Country:US
Practice Address - Phone:304-531-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV45764787987Medicaid