Provider Demographics
NPI:1740397470
Name:MINNIE HAMILTON HEALTH CARE CENTER, INC
Entity Type:Organization
Organization Name:MINNIE HAMILTON HEALTH CARE CENTER, INC
Other - Org Name:GILMER OFFICE - MEDICARE - FQHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WHITED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-354-9244
Mailing Address - Street 1:186 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26147-7100
Mailing Address - Country:US
Mailing Address - Phone:304-354-9244
Mailing Address - Fax:304-354-9323
Practice Address - Street 1:809 MINERAL RD STE 1
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:WV
Practice Address - Zip Code:26351-1385
Practice Address - Country:US
Practice Address - Phone:304-354-9244
Practice Address - Fax:304-354-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV150261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5369001-000Medicaid