Provider Demographics
NPI:1639578065
Name:TUG RIVER HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-448-2101
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:RR 103 SUPPLY STREET
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836-0507
Mailing Address - Country:US
Mailing Address - Phone:304-448-2101
Mailing Address - Fax:304-448-3217
Practice Address - Street 1:RR 103 SUPPLY STREET
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:WV
Practice Address - Zip Code:24836-0507
Practice Address - Country:US
Practice Address - Phone:304-448-2101
Practice Address - Fax:304-448-3217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)