Full Name | |
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Speciality | Clinic/Center |
Location | 920 Elm St, Racine, Ohio |
Authorized Official Name and Position | Vicki L Knicely (BILLING/CREDENTIALING SUPERVISOR) |
Authorized Official Contact | 3042753301 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Po Box 609 Elizabeth WV 26143-0609 Ph: (304) 275-3301 | 920 Elm St Racine OH 45771-8902 Ph: (740) 949-2348 |
NPI Number | 1366762825 |
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Provider Enumeration Date | 06/08/2010 |
Last Update Date | 09/07/2023 |
Medicare PECOS PAC ID | 7810806577 |
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Medicare Enrollment ID | O20110426000178 |
Identifier | Type | State | Issuer |
---|---|---|---|
1366762825 | NPI | - | NPPES |
0085471 | Medicaid | OH |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |