Provider Demographics
NPI:1518191923
Name:WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC
Entity Type:Organization
Organization Name:WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC
Other - Org Name:WIRT COUNTY SCHOOL WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING/CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KNICELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-275-3301
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:WV
Mailing Address - Zip Code:26143-0609
Mailing Address - Country:US
Mailing Address - Phone:304-275-3301
Mailing Address - Fax:304-275-4798
Practice Address - Street 1:SCHOOLVIEW STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:WV
Practice Address - Zip Code:26143
Practice Address - Country:US
Practice Address - Phone:304-275-3117
Practice Address - Fax:304-275-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0009486002Medicaid
WV511863Medicare Oscar/Certification
WV5118631Medicare PIN