Provider Demographics
NPI:1558653741
Name:CLINCH RIVER HEALTH SERVICES INC
Entity Type:Organization
Organization Name:CLINCH RIVER HEALTH SERVICES INC
Other - Org Name:CLINCH RIVER HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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:PO BOX 4710
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-4710
Mailing Address - Country:US
Mailing Address - Phone:804-237-7690
Mailing Address - Fax:
Practice Address - Street 1:17285 VETERANS MEMORIAL HWY
Practice Address - Street 2:
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:2011-05-06
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
VAC01409Medicare PIN
491824Medicare Oscar/Certification