Basic Information
Provider Information | |||||||||
NPI: | 1366762825 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHERN LOCAL SCHOOL DISTRICT WELLNESS CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 609 | ||||||||
Address2: |   | ||||||||
City: | ELIZABETH | ||||||||
State: | WV | ||||||||
PostalCode: | 261430609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042753301 | ||||||||
FaxNumber: | 3042754798 | ||||||||
Practice Location | |||||||||
Address1: | 906 ELM ST | ||||||||
Address2: |   | ||||||||
City: | RACINE | ||||||||
State: | OH | ||||||||
PostalCode: | 457718902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7409494222 | ||||||||
FaxNumber: | 7409491101 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2010 | ||||||||
LastUpdateDate: | 01/03/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KNICELY | ||||||||
AuthorizedOfficialFirstName: | VICKI | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING/CREDENTIALING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 3042753301 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 0085471 | 05 | OH |   | MEDICAID |