1033364765 NPI number — TUG RIVER HEALTH ASSOCIATION

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 1033364765 NPI number — TUG RIVER HEALTH ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUG RIVER HEALTH ASSOCIATION
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:
6
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:
1033364765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 507
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24836-0507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-448-2101
Provider Business Mailing Address Fax Number:
304-448-3217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US ROUTE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24874-0430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-732-7069
Provider Business Practice Location Address Fax Number:
304-732-7098
Provider Enumeration Date:
11/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
304-448-2101

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51D0233700 . This is a "CLIA CERT #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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