Provider Demographics
NPI:1376818526
Name:MCDOWELL COUNTY COMMISSION ON AGING, INC.
Entity Type:Organization
Organization Name:MCDOWELL COUNTY COMMISSION ON AGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-436-6588
Mailing Address - Street 1:725 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:WV
Mailing Address - Zip Code:24801-2125
Mailing Address - Country:US
Mailing Address - Phone:304-436-6588
Mailing Address - Fax:304-436-2006
Practice Address - Street 1:725 STEWART ST
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2125
Practice Address - Country:US
Practice Address - Phone:304-436-6588
Practice Address - Fax:304-436-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVFE271147253Z00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1134348253OtherMEDICAID WAIVER
WV1316166432Medicaid