Basic Information
| Provider Information | |||||||||
| NPI: | 1609983691 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINNIE HAMILTON HEALTH CARE CENTER, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RURAL HEALTH CLINIC - MEDICARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 186 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | GRANTSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261477100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043549244 | ||||||||
| FaxNumber: | 3043549323 | ||||||||
| Practice Location | |||||||||
| Address1: | 186 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | GRANTSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261477100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043549244 | ||||||||
| FaxNumber: | 3043549323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHITED | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/COO | ||||||||
| AuthorizedOfficialTelephone: | 3043549244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 150 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 513998 | 01 | WV | RURAL HEALTH CLINIC | OTHER |