Provider Demographics
NPI:1023348448
Name:MOUNTAIN STATE WELLNESS, PLLC
Entity type:Organization
Organization Name:MOUNTAIN STATE WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:WATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-292-7740
Mailing Address - Street 1:965 HARTMAN RUN RD
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-7700
Mailing Address - Country:US
Mailing Address - Phone:304-292-7740
Mailing Address - Fax:
Practice Address - Street 1:965 HARTMAN RUN RD
Practice Address - Street 2:SUITE 1101
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-7700
Practice Address - Country:US
Practice Address - Phone:304-292-7740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4082911Medicare PIN
WV4082901Medicare PIN