Basic Information
| Provider Information | |||||||||
| NPI: | 1316228166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOMENCARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILYCARE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 GREAT TEAYS BLVD | ||||||||
| Address2: | STE 6 | ||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3047573252 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253023351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044141899 | ||||||||
| FaxNumber: | 3044141886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2011 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | DIANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3047576999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2257-5026 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1316228166 | 05 | WV | MEDICAID | 3810024290 | 05 | WV | MEDICAID |