Basic Information
| Provider Information | |||||||||
| NPI: | 1760481147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINCH VALLEY MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PREFERRED HOME HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207000 | ||||||||
| FaxNumber: | 6159208913 | ||||||||
| Practice Location | |||||||||
| Address1: | 2011 2ND ST | ||||||||
| Address2: | |||||||||
| City: | RICHLANDS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246412305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769639577 | ||||||||
| FaxNumber: | 2769634747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 02/05/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SERAPHINE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6159207000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 133V00000X | N | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 008704279 | 05 | VA | MEDICAID | 4974999 | 05 | VA | MEDICAID | 8750572 | 05 | VA | MEDICAID | 010014492 | 05 | VA | MEDICAID | 010132274 | 05 | VA | MEDICAID |