Basic Information
Provider Information | |||||||||
NPI: | 1710165568 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONONGAHELA VALLEY ASSOCIATION OF HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MVA SHINNSTON MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1322 LOCUST AVE | ||||||||
Address2: | PO BOX 1122 | ||||||||
City: | FAIRMONT | ||||||||
State: | WV | ||||||||
PostalCode: | 265541436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043678710 | ||||||||
FaxNumber: | 3043669529 | ||||||||
Practice Location | |||||||||
Address1: | 1 COLUMBIA RD | ||||||||
Address2: |   | ||||||||
City: | SHINNSTON | ||||||||
State: | WV | ||||||||
PostalCode: | 264311016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045921040 | ||||||||
FaxNumber: | 3045925317 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/04/2008 | ||||||||
LastUpdateDate: | 03/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VANDERGRIFT | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3043678740 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.