Provider Demographics
NPI:1548749062
Name:TUG RIVER HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION, INC.
Other - Org Name:TUG RIVER HEALTH ASSOCIATION
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:PO BOX 507
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836
Mailing Address - Country:US
Mailing Address - Phone:304-448-2101
Mailing Address - Fax:304-448-3217
Practice Address - Street 1:950 MOUNT VIEW RD
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2810
Practice Address - Country:US
Practice Address - Phone:304-448-2101
Practice Address - Fax:304-448-3217
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
WV51D1064007291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005540Medicaid