Provider Demographics
NPI:1376761304
Name:JUNCTION CENTER FOR INDEPENDENT LIVING, INC.
Entity Type:Organization
Organization Name:JUNCTION CENTER FOR INDEPENDENT LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-524-4081
Mailing Address - Street 1:1520 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-3114
Mailing Address - Country:US
Mailing Address - Phone:276-524-4081
Mailing Address - Fax:276-524-1510
Practice Address - Street 1:1520 3RD AVE E
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3114
Practice Address - Country:US
Practice Address - Phone:276-524-4081
Practice Address - Fax:276-524-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA008744041171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008744041Medicaid
VA008743908Medicaid
VA1376761304Medicaid