Provider Demographics
NPI:1710104260
Name:ST CHARLES HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:ST CHARLES HEALTH COUNCIL INC
Other - Org Name:WILLIAM A DAVIS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-546-5310
Mailing Address - Street 1:CLINIC DRIVE
Mailing Address - Street 2:HIGHWAY 63 NORTH
Mailing Address - City:ST PAUL
Mailing Address - State:VA
Mailing Address - Zip Code:24283
Mailing Address - Country:US
Mailing Address - Phone:276-762-0770
Mailing Address - Fax:276-762-0678
Practice Address - Street 1:1389 DANTE ROAD
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:VA
Practice Address - Zip Code:24283
Practice Address - Country:US
Practice Address - Phone:276-762-0770
Practice Address - Fax:276-762-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007602979Medicaid
VA007602979Medicaid
VA491815Medicare Oscar/Certification