Basic Information
| Provider Information | |||||||||
| NPI: | 1013675461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN COUNTY PRIMARY CARE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048245804 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 MARLAND AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048245804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2021 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | LETITIA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3048245806 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2410-9259 | 01 | WV | BUSINESS LICNESE | OTHER |