Provider Demographics
NPI:1114955168
Name:CLINCH VALLEY UROLOGY, LLC
Entity Type:Organization
Organization Name:CLINCH VALLEY UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-565-1508
Mailing Address - Street 1:6719 GOV G. C. PEERY HWY
Mailing Address - Street 2:SUITE 3650
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641-2055
Mailing Address - Country:US
Mailing Address - Phone:276-596-6773
Mailing Address - Fax:866-803-1898
Practice Address - Street 1:6719 GOV G. C. PEERY HWY
Practice Address - Street 2:SUITE 1800
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-2055
Practice Address - Country:US
Practice Address - Phone:276-596-6659
Practice Address - Fax:276-596-6658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1114955168Medicaid
VA1114955168Medicaid