Provider Demographics
NPI:1407922891
Name:TUG RIVER HEALTH ASSOCIATION, INC
Entity Type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION, INC
Other - Org Name:PINEVILLE CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-448-2101
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836-0507
Mailing Address - Country:US
Mailing Address - Phone:304-448-2101
Mailing Address - Fax:304-448-3217
Practice Address - Street 1:US ROUTE 103 SUPPLY ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:WV
Practice Address - Zip Code:24836
Practice Address - Country:US
Practice Address - Phone:304-732-7069
Practice Address - Fax:304-732-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014476Medicaid
F18465Medicare UPIN
WV511943Medicare Oscar/Certification
WV5119431Medicare PIN