Basic Information
Provider Information
NPI: 1942523931
EntityType: 2
ReplacementNPI:  
OrganizationName: LINCOLN COUNTY PRIMARY CARE CENTER, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SOUTHERN WEST VIRIGNIA HEALTH SYSTEM-GILBERT
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7400 LYNN AVE
Address2:  
City: HAMLIN
State: WV
PostalCode: 255231138
CountryCode: US
TelephoneNumber: 3048245806
FaxNumber: 3048245885
Practice Location
Address1: 202 LARRY JOE HARLESS DRIVE
Address2: SUITE 205
City: GILBERT
State: WV
PostalCode: 256211842
CountryCode: US
TelephoneNumber: 3046646270
FaxNumber: 3046646272
Other Information
ProviderEnumerationDate: 03/05/2010
LastUpdateDate: 10/02/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LEACH
AuthorizedOfficialFirstName: LISA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 3048245806
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QF0400X  Y Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
381001938705WV MEDICAID


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