| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 3 Adena Dr, Kermit, West Virginia |
| Authorized Official Name and Position | Mary-beth Brubeck (VICE PRESIDENT OF FINANCE / CFO) |
| Authorized Official Contact | 3045253334 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
2585 3rd Ave Huntington WV 25703-1642 Ph: (304) 697-1396 | 3 Adena Dr Kermit WV 25674-8063 Ph: (304) 393-4090 |
| NPI Number | 1720054489 |
|---|---|
| Provider Enumeration Date | 02/23/2006 |
| Last Update Date | 03/31/2022 |
| Certification Date | 03/31/2022 |
| Medicare PECOS PAC ID | 9931017969 |
|---|---|
| Medicare Enrollment ID | O20030616000031 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720054489 | NPI | - | NPPES |
| 6592630500 | Medicaid | KY | |
| CJ2698 | Other | WV | RR MEDICARE GROUP |
| 7100226540 | Medicaid | KY | |
| 0035275000 | Medicaid | WV |