Provider Demographics
NPI:1407259062
Name:CLENDENIN HEALTH CENTER LAB
Entity Type:Organization
Organization Name:CLENDENIN HEALTH CENTER LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-734-2040
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:DAWES
Mailing Address - State:WV
Mailing Address - Zip Code:25054-0070
Mailing Address - Country:US
Mailing Address - Phone:304-734-2040
Mailing Address - Fax:304-734-2047
Practice Address - Street 1:107 KOONTZ AVE STE 200
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045-9581
Practice Address - Country:US
Practice Address - Phone:304-734-2040
Practice Address - Fax:301-734-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVC703Medicare PIN