Provider Demographics
NPI:1639235310
Name:CLINIC IV INC
Entity Type:Organization
Organization Name:CLINIC IV INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-425-9592
Mailing Address - Street 1:100 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2143
Mailing Address - Country:US
Mailing Address - Phone:304-425-9592
Mailing Address - Fax:304-487-8967
Practice Address - Street 1:100 NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2143
Practice Address - Country:US
Practice Address - Phone:304-425-9592
Practice Address - Fax:304-487-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552254251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0144276001Medicaid
WV0144276001Medicaid