Provider Demographics
NPI:1366437121
Name:PENCE, TIMOTHY W (CH)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
Last Name:PENCE
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 82 BOX 10
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9501
Mailing Address - Country:US
Mailing Address - Phone:304-645-6080
Mailing Address - Fax:304-645-2825
Practice Address - Street 1:HC 82 BOX 10
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9501
Practice Address - Country:US
Practice Address - Phone:304-645-6080
Practice Address - Fax:304-645-2825
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV536111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0131742000Medicaid
WV0131742000Medicaid
WVPE0725703Medicare ID - Type Unspecified