Provider Demographics
NPI:1225114184
Name:COUNCIL OF THE SOUTHERN MOUNTAINS, WV BRANCH, MCDOWELL CO CHAPTER, INC
Entity Type:Organization
Organization Name:COUNCIL OF THE SOUTHERN MOUNTAINS, WV BRANCH, MCDOWELL CO CHAPTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:304-862-3144
Mailing Address - Street 1:PO BOX 85
Mailing Address - Street 2:
Mailing Address - City:NORTHFORK
Mailing Address - State:WV
Mailing Address - Zip Code:24868-0085
Mailing Address - Country:US
Mailing Address - Phone:304-862-3144
Mailing Address - Fax:304-862-3071
Practice Address - Street 1:69 MAIN STREET
Practice Address - Street 2:CITY OF KEYSTONE BUILDING
Practice Address - City:KEYSTONE
Practice Address - State:WV
Practice Address - Zip Code:24868-0085
Practice Address - Country:US
Practice Address - Phone:304-862-3144
Practice Address - Fax:304-862-3071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3810005980251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005980Medicaid