Provider Demographics
NPI:1346442134
Name:PENDLETON COMMUNITY CARE, INC.
Entity Type:Organization
Organization Name:PENDLETON COMMUNITY CARE, INC.
Other - Org Name:NORTH FORK PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-358-7230
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WV
Mailing Address - Zip Code:26814-0101
Mailing Address - Country:US
Mailing Address - Phone:304-567-2101
Mailing Address - Fax:304-567-2102
Practice Address - Street 1:16921 MOUNTAINEER DRIVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WV
Practice Address - Zip Code:26814-0101
Practice Address - Country:US
Practice Address - Phone:304-567-2101
Practice Address - Fax:304-567-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D0661868291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006211Medicaid
WV3810006211Medicaid