Provider Demographics
NPI:1336106632
Name:COMMUNITY HEALTH FOUNDATION OF LOGAN
Entity Type:Organization
Organization Name:COMMUNITY HEALTH FOUNDATION OF LOGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ROSCOE
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:304-583-6541
Mailing Address - Street 1:HC68 BOX 1000
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-9620
Mailing Address - Country:US
Mailing Address - Phone:304-239-3888
Mailing Address - Fax:304-239-3811
Practice Address - Street 1:HC68 BOX 1000
Practice Address - Street 2:SUITE 3
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-9620
Practice Address - Country:US
Practice Address - Phone:304-239-3888
Practice Address - Fax:304-239-3811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004108Medicaid
WV511903Medicare ID - Type Unspecified