1417931379 NPI number — PENDLETON COMMUNITY CARE, INC.

Table of content: (NPI 1417931379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417931379 NPI number — PENDLETON COMMUNITY CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENDLETON COMMUNITY CARE, 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:
NORTH FORK PRIMARY CARE CLINIC
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:
1417931379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26814-0101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-567-2101
Provider Business Mailing Address Fax Number:
304-567-2102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16921 MOUNTAINEER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26814-0101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-567-2101
Provider Business Practice Location Address Fax Number:
304-567-2102
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HUDSON
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
304-358-7230

Provider Taxonomy Codes

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

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

  • Identifier: 001706795 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 5369042000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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