1205525276 NPI number — LOGAN-MINGO AREA MENTAL HEALTH, INC

Table of content: (NPI 1205525276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205525276 NPI number — LOGAN-MINGO AREA MENTAL HEALTH, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGAN-MINGO AREA MENTAL HEALTH, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOUNTAIN LAUREL INTEGRATED HEALTHCARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205525276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 176
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25601-0176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-792-7130
Provider Business Mailing Address Fax Number:
304-896-5184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
174 LMAH CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-792-7130
Provider Business Practice Location Address Fax Number:
304-896-5184
Provider Enumeration Date:
05/04/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTSON
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR HUMAN RESOURCES
Authorized Official Telephone Number:
304-792-7130

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5059060 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: SP0552603 . This is a "PHARMACY LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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