Provider Demographics
NPI:1821402348
Name:WASHINGTON COUNTY FREE CLINIC INC
Entity Type:Organization
Organization Name:WASHINGTON COUNTY FREE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOZIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-376-0261
Mailing Address - Street 1:PO BOX 804
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0804
Mailing Address - Country:US
Mailing Address - Phone:740-376-0261
Mailing Address - Fax:740-376-7160
Practice Address - Street 1:208 3RD ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3001
Practice Address - Country:US
Practice Address - Phone:740-376-0261
Practice Address - Fax:740-376-7160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
OH261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36D2003526OtherCLIA WAIVER