Basic Information
| Provider Information | |||||||||
| NPI: | 1801836341 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CABIN CREEK HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SISSONVILLE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7133 SISSONVILLE DR | ||||||||
| Address2: | |||||||||
| City: | SISSONVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253209738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049841576 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7133 SISSONVILLE DR | ||||||||
| Address2: | |||||||||
| City: | SISSONVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253209738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049841576 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3047342040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 031820 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 3810005146 | 05 | WV | MEDICAID | 3810006994 | 05 | WV | MEDICAID |