Provider Demographics
NPI:1154473296
Name:CLINCH VALLEY NEPHROLOGY INC
Entity Type:Organization
Organization Name:CLINCH VALLEY NEPHROLOGY INC
Other - Org Name:RICHLANDS EXPRESS DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IN
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-964-4001
Mailing Address - Street 1:2951 W FRONT STREET
Mailing Address - Street 2:CVMP SUITE 1600
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641
Mailing Address - Country:US
Mailing Address - Phone:276-964-4001
Mailing Address - Fax:276-964-4003
Practice Address - Street 1:2951 W FRONT STREET
Practice Address - Street 2:CVMP SUITE B800
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641
Practice Address - Country:US
Practice Address - Phone:276-964-4001
Practice Address - Fax:276-964-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA442324OtherANTHEM
VA492544Medicare ID - Type Unspecified