Basic Information
| Provider Information | |||||||||
| NPI: | 1689773327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VANSCOY CHIROPRACTIC CORPORATION HOLISTIC HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TEAYS VALLEY MEDICINE AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3761 TEAYS VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074760118 | ||||||||
| FaxNumber: | 3047601189 | ||||||||
| Practice Location | |||||||||
| Address1: | 3761 TEAYS VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074760118 | ||||||||
| FaxNumber: | 3047601189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | VANSCOY | ||||||||
| AuthorizedOfficialFirstName: | DARRIN | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3047601180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NX0800X | 729 | WV | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Orthopedic | 204C00000X | 940 | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH0555 | 01 | WV | RAILROAD MEDICARE NUMBER | OTHER | 4000457000 | 05 | WV | MEDICAID | 9309691 | 01 | WV | MEDICARE GROUP NUMBER | OTHER |