| Mountain State Recovery Center | |
|
102 Patrick Street Plz Charleston WV 25387-2444 | |
| (304) 941-9779 | |
| Not Available |
| Full Name | Mountain State Recovery Center |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 102 Patrick Street Plz, Charleston, West Virginia |
| Authorized Official Name and Position | Joseph Shaffer (COO) |
| Authorized Official Contact | 8594892705 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mountain State Recovery Center 8 River Walk Mall South Charleston WV 25303-1026 | Mountain State Recovery Center 102 Patrick Street Plz Charleston WV 25387-2444 Ph: (304) 941-9779 |
| NPI Number | 1194294587 |
|---|---|
| Provider Enumeration Date | 11/15/2018 |
| Last Update Date | 03/15/2024 |
| Certification Date | 03/15/2024 |
| Medicare PECOS PAC ID | 6800122896 |
|---|---|
| Medicare Enrollment ID | O20251103002648 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194294587 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | () | Primary |
| 291U00000X | Clinical Medical Laboratory | () | Secondary |
| Provider Name | James David Miller |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1710970801 PECOS PAC ID: 4284692831 Enrollment ID: I20041229000198 |
| Provider Name | Mark Mcdaniel |
|---|---|
| Provider Type | Practitioner - Addiction Medicine |
| Provider Identifiers | NPI Number: 1134230311 PECOS PAC ID: 2961441605 Enrollment ID: I20050502000765 |
| Provider Name | Tracie F Bonner |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1679709554 PECOS PAC ID: 5799838959 Enrollment ID: I20090805000480 |
| Provider Name | Olga S Minenko-mcdaniel |
|---|---|
| Provider Type | Practitioner - Hospitalist |
| Provider Identifiers | NPI Number: 1780884338 PECOS PAC ID: 4385814284 Enrollment ID: I20110901000527 |
| Provider Name | Lonnie Keith Sipsy |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1518925767 PECOS PAC ID: 8628033032 Enrollment ID: I20160128002419 |
| Provider Name | Angela Nicholson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1760845531 PECOS PAC ID: 1658668025 Enrollment ID: I20160928002187 |
| Provider Name | Sherry Copley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1811654361 PECOS PAC ID: 5698267540 Enrollment ID: I20251126003327 |
| Provider Name | Nakyra Willis |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1538906474 PECOS PAC ID: 6103391438 Enrollment ID: I20260406000074 |
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