Basic Information
| Provider Information | |||||||||
| NPI: | 1063932929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CABIN CREEK HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CABIN CREEK HEALTH CENTER, INC. AT KCHD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70 | ||||||||
| Address2: | |||||||||
| City: | DAWES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250540070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047342040 | ||||||||
| FaxNumber: | 3047342047 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 LEE ST E | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047342040 | ||||||||
| FaxNumber: | 3047342047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2017 | ||||||||
| LastUpdateDate: | 06/22/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 3047342040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CABIN CREEK HEALTH CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.