Provider Demographics
NPI:1225272214
Name:NEW RIVER HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:NEW RIVER HEALTH ASSOCIATION, INC.
Other - Org Name:LIVING WELL ELDER CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-469-2905
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-3180
Practice Address - Street 1:1614 S KANAWHA ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6239
Practice Address - Country:US
Practice Address - Phone:304-763-7723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW RIVER HEALTH ASSOCIATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-22
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1036-9138261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1036-9138OtherSTATE LICENSE
WV9160134Medicare PIN
WV15905Medicare PIN
WV1036-9138OtherSTATE LICENSE