Basic Information
| Provider Information | |||||||||
| NPI: | 1073756920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTRIDGE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 235 S WATER ST | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254014241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042638954 | ||||||||
| FaxNumber: | 3042638141 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 S WATER ST | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254014241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042638954 | ||||||||
| FaxNumber: | 3042638141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | MACOM | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3042638954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | BP00941825 | WV | Y | Agencies | Community/Behavioral Health |
No ID Information.