Basic Information
| Provider Information | |||||||||
| NPI: | 1558653741 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINCH RIVER HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLINCH RIVER HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4710 | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230584710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042377690 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17285 VETERANS MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | DUNGANNON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764672201 | ||||||||
| FaxNumber: | 2764672673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2011 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | GILLIAM | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2764672201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.