Basic Information
| Provider Information | |||||||||
| NPI: | 1346227584 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI AREA COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRI AREA COMMUNITY HEALTH AT LAUREL FORK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243520009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Practice Location | |||||||||
| Address1: | 14558 DANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243523758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 09/09/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHELOR | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2763982292 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
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 | 007608942 | 05 | VA | MEDICAID |