Full Name | |
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Speciality | Clinic/Center |
Location | 1389 Dante Road, St Paul, Virginia |
Authorized Official Name and Position | Malcolm Perdue (CEO) |
Authorized Official Contact | 2765465310 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Clinic Drive Highway 63 North St Paul VA 24283 Ph: (276) 762-0770 | 1389 Dante Road St Paul VA 24283 Ph: (276) 762-0770 |
NPI Number | 1710104260 |
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Provider Enumeration Date | 04/19/2007 |
Last Update Date | 07/29/2010 |
Medicare PECOS PAC ID | 0244124584 |
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Medicare Enrollment ID | O20070612000414 |
Identifier | Type | State | Issuer |
---|---|---|---|
1710104260 | NPI | - | NPPES |
007602979 | Medicaid | VA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |