1740417401 NPI number — NEW RIVER HEALTH ASSOCIATION, INC

Table of content: (NPI 1740417401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740417401 NPI number — NEW RIVER HEALTH ASSOCIATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW RIVER HEALTH ASSOCIATION, 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:
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:
1740417401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
497 MALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK HILL
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25901-6216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
262 OYLER AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK HILL
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25901-2639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-465-2171
Provider Business Practice Location Address Fax Number:
304-465-2173
Provider Enumeration Date:
06/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MARISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING OFFICER
Authorized Official Telephone Number:
304-469-2905

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  1036-9138 , 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: 0035165000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810020556 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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