Basic Information
Provider Information | |||||||||
NPI: | 1366495525 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CABIN CREEK HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 70 | ||||||||
Address2: |   | ||||||||
City: | DAWES | ||||||||
State: | WV | ||||||||
PostalCode: | 250540070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3047342040 | ||||||||
FaxNumber: | 3047342047 | ||||||||
Practice Location | |||||||||
Address1: | ROUTE 79 | ||||||||
Address2: |   | ||||||||
City: | DAWES | ||||||||
State: | WV | ||||||||
PostalCode: | 250540070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3047342040 | ||||||||
FaxNumber: | 3047342047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 04/22/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBINSON | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: | H. | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3047342040 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 031820 | WV | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 001881671 | 01 | WV | MS BCBS | OTHER | 001710317 | 01 | WV | MS BCBS | OTHER | 001835095 | 01 | WV | MS BCBS | OTHER | 0905008000 | 05 | WV |   | MEDICAID |