Provider Demographics
NPI:1962696682
Name:PETERSTOWN WELLNESS CENTER
Entity type:Organization
Organization Name:PETERSTOWN WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-772-3064
Mailing Address - Street 1:108 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:PETERSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:24963
Mailing Address - Country:US
Mailing Address - Phone:304-753-6960
Mailing Address - Fax:304-753-6961
Practice Address - Street 1:200 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:WV
Practice Address - Zip Code:24983
Practice Address - Country:US
Practice Address - Phone:304-772-3064
Practice Address - Fax:304-772-3296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty