Provider Demographics
NPI:1639842818
Name:TUG RIVER HEALTH ASSOCIATION, INC
Entity Type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION, INC
Other - Org Name:TUG RIVER HEALTH ASSOCIATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:G
Authorized Official - Last Name:AGNEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-862-2588
Mailing Address - Street 1:200 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2329
Mailing Address - Country:US
Mailing Address - Phone:304-431-1400
Mailing Address - Fax:
Practice Address - Street 1:200 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2329
Practice Address - Country:US
Practice Address - Phone:304-431-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUG RIVER HEALTH ASSOCIATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-26
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1639842818Medicaid