Provider Demographics
NPI:1598747172
Name:FC OF WEST VIRGINIA INC
Entity Type:Organization
Organization Name:FC OF WEST VIRGINIA INC
Other - Org Name:INTREPID USA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-947-7700
Mailing Address - Street 1:3105 S MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-1022
Mailing Address - Country:US
Mailing Address - Phone:405-947-7700
Mailing Address - Fax:405-947-7300
Practice Address - Street 1:2110 LUMBER AVE STE 1
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5390
Practice Address - Country:US
Practice Address - Phone:304-242-2498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0004521000Medicaid
517034Medicare Oscar/Certification