Basic Information
| Provider Information | |||||||||
| NPI: | 1093022287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IRONTON & LAWRENCE COUNTY AREA COMMUNITY ACTION ORGANIZATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IRONTON HEALTH CARE CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405323534 | ||||||||
| FaxNumber: | 7405320027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1408 CAMPBELL DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405349202 | ||||||||
| FaxNumber: | 7405349327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2010 | ||||||||
| LastUpdateDate: | 01/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTH SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7405323534 | ||||||||
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| 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 | 3138527 | 05 | OH | MEDICAID | 3810021176 | 05 | WV | MEDICAID | 7100172810 | 05 | KY | MEDICAID |