Provider Demographics
NPI:1508845389
Name:CLINCH RIVER HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:CLINCH RIVER HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-467-2201
Mailing Address - Street 1:17633 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DUNGANNON
Mailing Address - State:VA
Mailing Address - Zip Code:24245
Mailing Address - Country:US
Mailing Address - Phone:276-467-2201
Mailing Address - Fax:276-467-2673
Practice Address - Street 1:17633 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:DUNGANNON
Practice Address - State:VA
Practice Address - Zip Code:24245
Practice Address - Country:US
Practice Address - Phone:276-467-2201
Practice Address - Fax:276-467-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007639431Medicaid
VAC01409Medicare PIN