Basic Information
| Provider Information | |||||||||
| NPI: | 1699797829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRICH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT,MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 TRACY WAY | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434583 | ||||||||
| FaxNumber: | 3043439207 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 TRACY WAY | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434583 | ||||||||
| FaxNumber: | 3043439207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1358 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.