Basic Information
| Provider Information | |||||||||
| NPI: | 1790257798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN COUNTY PRIMARY CARE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048245885 | ||||||||
| Practice Location | |||||||||
| Address1: | 471 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251301223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043695170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2019 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | LETITIA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3048245806 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2362-7476 | 01 | WV | LICENSE | OTHER |