Basic Information
Provider Information | |||||||||
NPI: | 1548413982 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONONGAHELA VALLEY ASSOCIATION OF HEALTH CENTERS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SHINNSTON CLINICAL LAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1322 LOCUST AVE | ||||||||
Address2: | PO BOX 1112 | ||||||||
City: | FAIRMONT | ||||||||
State: | WV | ||||||||
PostalCode: | 265541436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043660700 | ||||||||
FaxNumber: | 3043669529 | ||||||||
Practice Location | |||||||||
Address1: | 1 COLUMBIA RD | ||||||||
Address2: |   | ||||||||
City: | SHINNSTON | ||||||||
State: | WV | ||||||||
PostalCode: | 264311016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045921040 | ||||||||
FaxNumber: | 3045925317 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2008 | ||||||||
LastUpdateDate: | 08/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VANDERGRIFT | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3043660700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 51D0236497 | 01 | WV | CLIA # | OTHER |