Basic Information
Provider Information | |||||||||
NPI: | 1144342270 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. CHARLES HEALTH COUNCIL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST. CHARLES COMMUNITY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 241 MONARCH RD | ||||||||
Address2: |   | ||||||||
City: | SAINT CHARLES | ||||||||
State: | VA | ||||||||
PostalCode: | 242828122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2763834428 | ||||||||
FaxNumber: | 2763834927 | ||||||||
Practice Location | |||||||||
Address1: | 100 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | ST. CHARLES | ||||||||
State: | VA | ||||||||
PostalCode: | 24282 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2763834428 | ||||||||
FaxNumber: | 2763834927 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2007 | ||||||||
LastUpdateDate: | 07/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PERDUE | ||||||||
AuthorizedOfficialFirstName: | MALCOLM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2765465310 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2021 |
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 | 007601867 | 05 | VA |   | MEDICAID |