Provider Demographics
NPI:1548615305
Name:PRESTON-TAYLOR COMMUNITY HEALTH CENTERS, INCORPORATED
Entity Type:Organization
Organization Name:PRESTON-TAYLOR COMMUNITY HEALTH CENTERS, INCORPORATED
Other - Org Name:DENTAL CENTER OF TAYLOR COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHRIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-265-0312
Mailing Address - Street 1:P.O. BOX 399
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1270
Mailing Address - Country:US
Mailing Address - Phone:304-265-0312
Mailing Address - Fax:304-265-0314
Practice Address - Street 1:711 N PIKE ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1221
Practice Address - Country:US
Practice Address - Phone:304-265-4600
Practice Address - Fax:304-265-6008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESTON-TAYLOR COMMUNITY HEALTH CENTERS, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1039-5432261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0035347002Medicaid