Basic Information
| Provider Information | |||||||||
| NPI: | 1225150824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST CHARLES HEALTH COUNCIL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KONNAROCK FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20471 AZEN RD | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242364141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763883411 | ||||||||
| FaxNumber: | 2763883732 | ||||||||
| Practice Location | |||||||||
| Address1: | 20471 AZEN RD | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242364141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763883411 | ||||||||
| FaxNumber: | 2763883732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERDUE | ||||||||
| AuthorizedOfficialFirstName: | MALCOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2765465310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| 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 | 007604092 | 05 | VA | MEDICAID |