| Full Name | |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 59 Greyhound Ln, Smithers, West Virginia |
| Authorized Official Name and Position | Marissa Johnson (CREDENTIALING OFFICER) |
| Authorized Official Contact | 3044692905 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 337 Scarbro WV 25917-0337 Ph: (304) 465-1378 | 59 Greyhound Ln Smithers WV 25186 Ph: (304) 981-4983 |
| NPI Number | 1467896969 |
|---|---|
| Provider Enumeration Date | 04/26/2013 |
| Last Update Date | 10/21/2019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1467896969 | NPI | - | NPPES |
| 1467896969 | Medicaid | WV |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | 1036-9138 (West Virginia) | Primary |