Provider Demographics
NPI:1033364765
Name:TUG RIVER HEALTH ASSOCIATION
Entity Type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION
Other - Org Name:PINEVILLE CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-448-2101
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836-0507
Mailing Address - Country:US
Mailing Address - Phone:304-448-2101
Mailing Address - Fax:304-448-3217
Practice Address - Street 1:US ROUTE 10
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874-0430
Practice Address - Country:US
Practice Address - Phone:304-732-7069
Practice Address - Fax:304-732-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV51D0233700OtherCLIA CERT #