Provider Demographics
NPI:1548450174
Name:APPALACHIAN FAMILY MEDICINE LAB
Entity type:Organization
Organization Name:APPALACHIAN FAMILY MEDICINE LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DICRISTOFARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-757-7788
Mailing Address - Street 1:104 STATION PLACE WAY
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8747
Mailing Address - Country:US
Mailing Address - Phone:304-757-7788
Mailing Address - Fax:304-201-1140
Practice Address - Street 1:104 STATION PLACE WAY
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8747
Practice Address - Country:US
Practice Address - Phone:304-757-7788
Practice Address - Fax:304-201-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5630468003Medicaid