Provider Demographics
NPI:1104044510
Name:PRIDE IN LOGAN COUNTY INC.
Entity Type:Organization
Organization Name:PRIDE IN LOGAN COUNTY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-752-2585
Mailing Address - Street 1:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-1346
Mailing Address - Country:US
Mailing Address - Phone:304-752-2585
Mailing Address - Fax:304-752-1047
Practice Address - Street 1:699 STRATTON ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4020
Practice Address - Country:US
Practice Address - Phone:304-752-2585
Practice Address - Fax:304-752-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030732002Medicaid