Basic Information
| Provider Information | |||||||||
| NPI: | 1538102827 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINCH VALLEY MEDICAL CENTER INC. | ||||||||
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| OtherOrganizationName: | CLINCH VALLEY MEDICAL CENTER - SNF UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207000 | ||||||||
| FaxNumber: | 6159208913 | ||||||||
| Practice Location | |||||||||
| Address1: | 6801 GOVERNOR GC PEERY HWY | ||||||||
| Address2: | |||||||||
| City: | RICHLANDS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246412194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765966000 | ||||||||
| FaxNumber: | 2765966009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLINCH VALLEY MEDICAL CENTER INC. | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004951816 | 05 | VA | MEDICAID | 000756 | 01 | VA | BLUE CROSS SNF PROVIDER NUMBER | OTHER |