Provider Demographics
NPI:1003274580
Name:LINCOLN COUNTY PRIMARY CARE CENTER, INC
Entity Type:Organization
Organization Name:LINCOLN COUNTY PRIMARY CARE CENTER, INC
Other - Org Name:MUSTANG HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-824-5806
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5885
Practice Address - Street 1:267 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:ALUM CREEK
Practice Address - State:WV
Practice Address - Zip Code:25003-9591
Practice Address - Country:US
Practice Address - Phone:304-756-1007
Practice Address - Fax:304-756-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2317-5033261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1003274580Medicaid