Basic Information
| Provider Information | |||||||||
| NPI: | 1962583054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN COUNTY PRIMARY CARE CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LCHS PANTHER CENTER FOR HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 81 LINCOLN PANTHER WAY | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048246090 | ||||||||
| FaxNumber: | 3048246094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEACH | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3048245806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LINCOLN COUNTY PRIMARY CARE CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | CA9760 | 01 | WV | MEDICARE RR | OTHER | 3810011409 | 05 | WV | MEDICAID |