| |
228 Kanawha Avenue Burnsville WV 26335 | |
(304) 924-6262 | |
(304) 924-5460 |
Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 228 Kanawha Avenue, Burnsville, West Virginia |
Authorized Official Name and Position | Dora L Potasnik (CREDENTIALING COORDINATOR) |
Authorized Official Contact | 3045872541 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
Po Box 147 Clay WV 25043-0147 Ph: (304) 587-2541 | 228 Kanawha Avenue Burnsville WV 26335 Ph: (304) 924-6262 |
NPI Number | 1871003178 |
---|---|
Provider Enumeration Date | 10/02/2017 |
Last Update Date | 10/02/2017 |
Medicare PECOS PAC ID | 0446232987 |
---|---|
Medicare Enrollment ID | O20171116003214 |
Identifier | Type | State | Issuer |
---|---|---|---|
1871003178 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |