Provider Demographics
NPI:1710203419
Name:CITY OF SISTERSVILLE
Entity Type:Organization
Organization Name:CITY OF SISTERSVILLE
Other - Org Name:SISTERSVILLE RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHADOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-652-2611
Mailing Address - Street 1:314 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:SISTERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26175-1098
Mailing Address - Country:US
Mailing Address - Phone:304-652-2611
Mailing Address - Fax:304-652-1448
Practice Address - Street 1:305 CLAY ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175
Practice Address - Country:US
Practice Address - Phone:304-447-2038
Practice Address - Fax:304-447-3990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV513412261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018439Medicaid
513412Medicare Oscar/Certification