Basic Information
| Provider Information | |||||||||
| NPI: | 1063608081 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTINSVILLE HENRY COUNTY COALITION FOR HEALTH AND WELLNESS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BASSETT FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 E CHURCH ST | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | MARTINSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241126208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764035099 | ||||||||
| FaxNumber: | 2766382669 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 T B STANLEY HWY | ||||||||
| Address2: | |||||||||
| City: | BASSETT | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240556108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766291076 | ||||||||
| FaxNumber: | 2766292695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 12/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | JACKMAN | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2764035099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 1063608081 | 05 | VA | MEDICAID |