1083055081 NPI number — TRI-STATE COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1083055081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083055081 NPI number — TRI-STATE COMMUNITY HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE COMMUNITY HEALTH CENTER, 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:
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:
1083055081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 RAYLOC DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANCOCK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21750-1518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-678-5187
Provider Business Mailing Address Fax Number:
301-678-5797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
261 BERKMORE PL
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
BERKELEY SPRINGS
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25411-6247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-258-5790
Provider Business Practice Location Address Fax Number:
304-258-3745
Provider Enumeration Date:
07/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DESHONG
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
301-678-5187

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  2291-3644 , 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: 511021 . This is a "FQHC" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com