Basic Information
| Provider Information | |||||||||
| NPI: | 1487604120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VACCA | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 GRAND CENTRAL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042953060 | ||||||||
| FaxNumber: | 3042953068 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 GRAND CENTRAL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042953060 | ||||||||
| FaxNumber: | 3042953068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10914 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 002475 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3810002352 | 05 | WV | MEDICAID | 2564514 | 05 | OH | MEDICAID |