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601 Campbell Ave Sw Roanoke VA 24016-3531 | |
| (540) 339-9195 | |
| (540) 339-9197 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 601 Campbell Ave Sw, Roanoke, Virginia |
| Authorized Official Name and Position | Charles Robert Clingenpeel (DIRECTOR OF FINANCE) |
| Authorized Official Contact | 5403399195 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
601 Campbell Ave Sw Roanoke VA 24016-3531 Ph: (540) 339-9195 | 601 Campbell Ave Sw Roanoke VA 24016-3531 Ph: (540) 339-9195 |
| NPI Number | 1417072687 |
|---|---|
| Provider Enumeration Date | 03/20/2007 |
| Last Update Date | 12/06/2022 |
| Certification Date | 12/06/2022 |
| Medicare PECOS PAC ID | 3072643873 |
|---|---|
| Medicare Enrollment ID | O20200630002115 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1417072687 | NPI | - | NPPES |
| 010145023 | Medicaid | VA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 717 (Virginia) | Primary |
| Provider Name | David C Macdonald |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1558321976 PECOS PAC ID: 3173620002 Enrollment ID: I20070529000436 |
| Provider Name | Sarah Borchelt |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1083183057 PECOS PAC ID: 6305182445 Enrollment ID: I20190110003441 |
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