Basic Information
| Provider Information | |||||||||
| NPI: | 1356403703 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RIVERVALLEY HEALTH & WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 606 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | RAVENSWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042731033 | ||||||||
| FaxNumber: | 3042731034 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | RAVENSWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042731033 | ||||||||
| FaxNumber: | 3042731034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/03/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNICELY | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3042753301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0009486002 | 05 | WV | MEDICAID |