Provider Demographics
NPI:1861801078
Name:ADVANCED SPECIALTIES, P LLC
Entity type:Organization
Organization Name:ADVANCED SPECIALTIES, P LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTA
Authorized Official - Middle Name:FAITH
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-461-3879
Mailing Address - Street 1:PO BOX 5417
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-7505
Mailing Address - Country:US
Mailing Address - Phone:304-461-3879
Mailing Address - Fax:304-461-3848
Practice Address - Street 1:1717 HARPER RD
Practice Address - Street 2:3RD FLOOR, SUITE A
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3373
Practice Address - Country:US
Practice Address - Phone:304-461-3879
Practice Address - Fax:304-461-3848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2330208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty