Basic Information
Provider Information | |||||||||
NPI: | 1447618327 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WOMENCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILYCARE HEALTHCENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 2 CHATEAU LN | ||||||||
Address2: |   | ||||||||
City: | BARBOURSVILLE | ||||||||
State: | WV | ||||||||
PostalCode: | 255041626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3047369662 | ||||||||
FaxNumber: | 3047573252 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2016 | ||||||||
LastUpdateDate: | 05/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAY | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: | DIANNE | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3047576999 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | H80CS00827 | WV | N |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 2084P0800X | 23242347 | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1447618327 | 05 | WV |   | MEDICAID |