Provider Demographics
NPI:1114356037
Name:ST. MARY'S HEALTH WAGON
Entity Type:Organization
Organization Name:ST. MARY'S HEALTH WAGON
Other - Org Name:THE HEALTH WAGON
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:276-328-8850
Mailing Address - Street 1:5626 PATRIOT DRIVE
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-7070
Mailing Address - Country:US
Mailing Address - Phone:276-328-8850
Mailing Address - Fax:276-328-8853
Practice Address - Street 1:5626 PATRIOT DRIVE
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-7070
Practice Address - Country:US
Practice Address - Phone:276-328-8850
Practice Address - Fax:276-328-8853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty