Provider Demographics
NPI:1619185147
Name:RALEIGH COUNTY COMMISSION ON AGING, INC.
Entity Type:Organization
Organization Name:RALEIGH COUNTY COMMISSION ON AGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-255-1397
Mailing Address - Street 1:1614 S KANAWHA ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6239
Mailing Address - Country:US
Mailing Address - Phone:304-255-1397
Mailing Address - Fax:304-252-9360
Practice Address - Street 1:1614 S KANAWHA ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6239
Practice Address - Country:US
Practice Address - Phone:304-255-1397
Practice Address - Fax:304-252-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030745000Medicaid