Provider Demographics
NPI:1487818902
Name:ST. MARY'S HEALTH WAGON
Entity Type:Organization
Organization Name:ST. MARY'S HEALTH WAGON
Other - Org Name:THE HEALTH WAGON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-328-8850
Mailing Address - Street 1:233 CHASE ST.
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228
Mailing Address - Country:US
Mailing Address - Phone:276-926-2254
Mailing Address - Fax:
Practice Address - Street 1:233 CHASE ST.
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-926-2254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024128995261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health