Provider Demographics
NPI:1033778642
Name:KANAWHA COUNTY EMERGENCY AMBULANCE AUTHORITY HEALTH AND WELLNESS BOARD
Entity Type:Organization
Organization Name:KANAWHA COUNTY EMERGENCY AMBULANCE AUTHORITY HEALTH AND WELLNESS BOARD
Other - Org Name:KCEAA HEALTH AND WELLNESS CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIR, CHIEF OF MED SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:304-345-2312
Mailing Address - Street 1:601 BROOKS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1319
Mailing Address - Country:US
Mailing Address - Phone:304-346-8877
Mailing Address - Fax:304-414-5218
Practice Address - Street 1:601 BROOKS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1319
Practice Address - Country:US
Practice Address - Phone:304-346-8877
Practice Address - Fax:304-414-5218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-07
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care