Basic Information
| Provider Information | |||||||||
| NPI: | 1134256506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMC SPORTS MEDICINE AND REHAB--CROSS LANES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 CHEROKEE TRL | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257054105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042222112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 GOFF MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | CROSS LANES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253131419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887055 | ||||||||
| FaxNumber: | 3053887058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | ATHLETIC TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 3043887055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | MS, ATC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.