Basic Information
| Provider Information | |||||||||
| NPI: | 1003301912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW RIVER HEALTH ASSOCIATION, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAYETTEVILLE PK-8 SCHOOL BASED HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 337 | ||||||||
| Address2: | |||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044692905 | ||||||||
| FaxNumber: | 3044651518 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 W MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258401419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044692905 | ||||||||
| FaxNumber: | 3044692981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2018 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MARISSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3044692905 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEW RIVER HEALTH ASSOCIATION, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.