Provider Demographics
NPI:1457830978
Name:TUG RIVER HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION, INC.
Other - Org Name:PINEVILLE CHILDRENS CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING /BILLING COORD.
Authorized Official - Prefix:
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:RR 103 SUPPLY STREET
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:585 APPALACHIAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24817
Practice Address - Country:US
Practice Address - Phone:304-732-7069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D0233700291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014476Medicaid