1215158324 NPI number — CLINCH VALLEY TREATMENT CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215158324 NPI number — CLINCH VALLEY TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINCH VALLEY TREATMENT CENTER
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:
Provider Other Organization Name Type Code:
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:
1215158324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 TOWN HOLLOW RD
Provider Second Line Business Mailing Address:
CEDAR BLUFF
Provider Business Mailing Address City Name:
CEDAR BLUFF
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-963-3554
Provider Business Mailing Address Fax Number:
276-963-4653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 TOWN HOLLOW RD
Provider Second Line Business Practice Location Address:
CEDAR BLUFF
Provider Business Practice Location Address City Name:
CEDAR BLUFF
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-963-3554
Provider Business Practice Location Address Fax Number:
276-963-4653
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHIPPS
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
SUBSTANCE ABUSE COUNSELOR
Authorized Official Telephone Number:
276-963-3554

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  LVN-164 X00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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