Basic Information
Provider Information | |||||||||
NPI: | 1932293941 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RAINELLE MEDICAL CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEADOW BRIDGE CLINIC PAAS FQHC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 120 | ||||||||
Address2: |   | ||||||||
City: | MEADOW BRIDGE | ||||||||
State: | WV | ||||||||
PostalCode: | 25976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044847755 | ||||||||
FaxNumber: | 3044846205 | ||||||||
Practice Location | |||||||||
Address1: | 1502 MEADOW BRIDGE ROAD | ||||||||
Address2: |   | ||||||||
City: | MEADOW BRIDGE | ||||||||
State: | WV | ||||||||
PostalCode: | 25976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044847755 | ||||||||
FaxNumber: | 3044846205 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRICE | ||||||||
AuthorizedOfficialFirstName: | FLOYD | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3044386188 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 045967 |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 0035241003 | 05 | WV |   | MEDICAID |