Provider Demographics
NPI:1720586472
Name:LINCOLN COUNTY PRIMARY CARE CENTER INC
Entity Type:Organization
Organization Name:LINCOLN COUNTY PRIMARY CARE CENTER INC
Other - Org Name:SOUTHERN WEST VIRGINIA HEALTH SYSTEM-MADISON MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LETITIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-824-5806
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5804
Practice Address - Street 1:471 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1223
Practice Address - Country:US
Practice Address - Phone:304-369-5170
Practice Address - Fax:304-306-7982
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LINCOLN COUNTY PRIMARY CARE CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-29
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1720586472Medicaid