| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 113 5th St, Gassaway, West Virginia |
| Authorized Official Name and Position | Dora L Potasnik (CREDENTIALING) |
| 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 217 Rock Cave WV 26234-0217 Ph: (304) 924-6262 | 113 5th St Gassaway WV 26624-1224 Ph: (304) 364-5291 |
| NPI Number | 1447699723 |
|---|---|
| Provider Enumeration Date | 06/19/2013 |
| Last Update Date | 06/19/2013 |
| Medicare PECOS PAC ID | 0446232987 |
|---|---|
| Medicare Enrollment ID | O20140312000343 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1447699723 | NPI | - | NPPES |
| 2287-8808 | Other | WV | BUSINESS LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | 2287-8808 (West Virginia) | Primary |
Braxton Health Associates, Inc Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 617 River St, Gassaway, WV 26624 Phone: 304-364-8941 Fax: 304-364-8943 | |