Provider Demographics
NPI:1295033009
Name:TUG RIVER HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION, INC.
Other - Org Name:TUG RIVER/RIVER VIEW WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:CROFTON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:304-448-2101
Mailing Address - Street 1:ROUTE 103 SUPPLY STREET
Mailing Address - Street 2:PO BOX 507
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836-0507
Mailing Address - Country:US
Mailing Address - Phone:304-448-2101
Mailing Address - Fax:304-448-3217
Practice Address - Street 1:512 MOUNTAINEER HIGHWAY
Practice Address - Street 2:ROOM 1344
Practice Address - City:BRADSHAW
Practice Address - State:WV
Practice Address - Zip Code:24817-0000
Practice Address - Country:US
Practice Address - Phone:304-967-7682
Practice Address - Fax:304-967-7684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021840Medicaid
WV511973Medicare Oscar/Certification