Provider Demographics
NPI:1154439859
Name:PRESTON TAYLOR COMMUNITY HEALTH CENTERS, INCORPORATED
Entity Type:Organization
Organization Name:PRESTON TAYLOR COMMUNITY HEALTH CENTERS, INCORPORATED
Other - Org Name:NEWBURG CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHRIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-265-0312
Mailing Address - Street 1:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:NEWBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26410-0035
Mailing Address - Country:US
Mailing Address - Phone:304-892-2828
Mailing Address - Fax:304-892-2927
Practice Address - Street 1:2060 N. MOUNTAINEER HWY
Practice Address - Street 2:
Practice Address - City:NEWBURG
Practice Address - State:WV
Practice Address - Zip Code:26410-0159
Practice Address - Country:US
Practice Address - Phone:304-892-2812
Practice Address - Fax:304-892-2814
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESTON TAYLOR COMMUNITY HEALTH CENTERS, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-25
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0035308000Medicaid
WV511851Medicare Oscar/Certification
WV5118511Medicare PIN
WV0035308000Medicaid