1962532218 NPI number — CLINCH VALLEY FAMILY PODIATRY, PLLC

Table of content: (NPI 1962532218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962532218 NPI number — CLINCH VALLEY FAMILY PODIATRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINCH VALLEY FAMILY PODIATRY, PLLC
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:
1962532218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6719 GOVERNOR G.C. PEERY HWY
Provider Second Line Business Mailing Address:
SUITE 3800
Provider Business Mailing Address City Name:
RICHLANDS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-596-9346
Provider Business Mailing Address Fax Number:
276-596-9348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6719 GOVERNOR G.C. PEERY HWY
Provider Second Line Business Practice Location Address:
SUITE 3800
Provider Business Practice Location Address City Name:
RICHLANDS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-596-9346
Provider Business Practice Location Address Fax Number:
276-596-9348
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
276-964-2411

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  0103300952 , 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)

  • Identifier: 1962532218 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810006139 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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