Basic Information
| Provider Information | |||||||||
| NPI: | 1003274580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN COUNTY PRIMARY CARE CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MUSTANG HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048245885 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 MIDWAY RD | ||||||||
| Address2: | |||||||||
| City: | ALUM CREEK | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250039591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047561007 | ||||||||
| FaxNumber: | 3047561010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2016 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEACH | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3048245806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2317-5033 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1003274580 | 05 | WV | MEDICAID |