Provider Demographics
NPI:1093183774
Name:MINERAL COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:MINERAL COUNTY BOARD OF HEALTH
Other - Org Name:MINERAL COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:
Authorized Official - Credentials:RS
Authorized Official - Phone:130-478-8132
Mailing Address - Street 1:RR 3 BOX 3045
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-9401
Mailing Address - Country:US
Mailing Address - Phone:130-478-8132
Mailing Address - Fax:130-478-8602
Practice Address - Street 1:RR 3 BOX 3045
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-9401
Practice Address - Country:US
Practice Address - Phone:130-478-8132
Practice Address - Fax:130-478-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0021252000Medicaid
WV0021252000Medicaid