Provider Demographics
NPI:1003907676
Name:TWIN STATES FAMILY CARE CENTER
Entity Type:Organization
Organization Name:TWIN STATES FAMILY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-248-8096
Mailing Address - Street 1:PO BOX 19
Mailing Address - Street 2:
Mailing Address - City:NEMOURS
Mailing Address - State:WV
Mailing Address - Zip Code:24738-0019
Mailing Address - Country:US
Mailing Address - Phone:304-248-8096
Mailing Address - Fax:304-248-8096
Practice Address - Street 1:HIGHWAY 102
Practice Address - Street 2:
Practice Address - City:WOLFE
Practice Address - State:WV
Practice Address - Zip Code:24751
Practice Address - Country:US
Practice Address - Phone:304-248-8096
Practice Address - Fax:304-248-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11738WV207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0048928000Medicaid
=========OtherEIN
=========OtherEIN
D49360Medicare UPIN
WV0048928000Medicaid
500000190Medicare PIN