Basic Information
| Provider Information | |||||||||
| NPI: | 1558583450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACE | ||||||||
| FirstName: | SALLYE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 515 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047366126 | ||||||||
| FaxNumber: | 3047361531 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 FIRST AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047366126 | ||||||||
| FaxNumber: | 3047361531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 3810008043 | WV | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3810008043 | 05 | WV | MEDICAID |