Provider Demographics
NPI:1114047016
Name:ST CHARLES HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:ST CHARLES HEALTH COUNCIL INC
Other - Org Name:STONE MOUNTAIN HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-546-5310
Mailing Address - Street 1:2534 MENDOTA ROAD
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:VA
Mailing Address - Zip Code:24270
Mailing Address - Country:US
Mailing Address - Phone:276-645-6710
Mailing Address - Fax:
Practice Address - Street 1:2534 MENDOTA ROAD
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:VA
Practice Address - Zip Code:24270
Practice Address - Country:US
Practice Address - Phone:276-645-6710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1114047016Medicaid
VA1114047016Medicaid