Basic Information
| Provider Information | |||||||||
| NPI: | 1679695316 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CHARLES HEALTH COUNCIL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOLSTON FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 SOUTH SHADY AVENUE | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764755116 | ||||||||
| FaxNumber: | 2764755665 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 SOUTH SHADY AVENUE | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764755116 | ||||||||
| FaxNumber: | 2764755665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | PERDUE | ||||||||
| AuthorizedOfficialFirstName: | MALCOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2764755116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 007603002 | 05 | VA | MEDICAID |