1437199742 NPI number — CABIN CREEK HEALTH CENTER, INC.

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 1437199742 NPI number — CABIN CREEK HEALTH CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CABIN CREEK 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:
CLENDENIN HEALTH CENTER
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:
1437199742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 KOONTZ AVE.
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CLENDENIN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-548-4900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 KOONTZ AVE.
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CLENDENIN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-548-4900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
304-734-2040

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  031820 , 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: 001835095 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810005141 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001710317 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810006995 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001881671 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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