Provider Demographics
NPI:1891977070
Name:CABELL COUNTY COMMUNITY SERVICES ORGANIZATION, INC.
Entity Type:Organization
Organization Name:CABELL COUNTY COMMUNITY SERVICES ORGANIZATION, INC.
Other - Org Name:CCCSO
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:ROSWALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-529-4952
Mailing Address - Street 1:724 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2733
Mailing Address - Country:US
Mailing Address - Phone:304-529-4952
Mailing Address - Fax:304-525-2061
Practice Address - Street 1:724 10TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2733
Practice Address - Country:US
Practice Address - Phone:304-529-4952
Practice Address - Fax:304-525-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0030563001251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030563001Medicaid