Basic Information
| Provider Information | |||||||||
| NPI: | 1417976382 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED HEALTH CARE PROVIDERS, INC | ||||||||
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| OtherOrganizationName: | SPORTS MEDICINE & REHAB CENTER CROSS LANES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MORRIS ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887782 | ||||||||
| FaxNumber: | 3043887788 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 GOFF MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | CROSS LANES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253131419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887055 | ||||||||
| FaxNumber: | 3043887058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 04/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | GOODE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043887783 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3810006518 | 05 | WV | MEDICAID |