Provider Demographics
NPI:1619135167
Name:MONONGALIA COUNTY YOUTH SERVICE CENTER, INC.
Entity Type:Organization
Organization Name:MONONGALIA COUNTY YOUTH SERVICE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:304-599-2293
Mailing Address - Street 1:440 ELMER PRINCE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3273
Mailing Address - Country:US
Mailing Address - Phone:304-599-2293
Mailing Address - Fax:
Practice Address - Street 1:440 ELMER PRINCE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3273
Practice Address - Country:US
Practice Address - Phone:304-599-2293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0158457001Medicaid