Provider Demographics
NPI:1831491042
Name:MVA X-RAY FAIRMONT CLINIC
Entity Type:Organization
Organization Name:MVA X-RAY FAIRMONT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDERGRIFT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:304-367-8740
Mailing Address - Street 1:1322 LOCUST AVE
Mailing Address - Street 2:PO BOX 1112
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1436
Mailing Address - Country:US
Mailing Address - Phone:304-367-8740
Mailing Address - Fax:304-366-9529
Practice Address - Street 1:1322 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1436
Practice Address - Country:US
Practice Address - Phone:304-367-8740
Practice Address - Fax:304-366-9529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONONGAHELA VALLEY ASSOCIATION OF HEALTH CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-19
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1034-6686261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0121537000Medicaid
WV0121537000Medicaid