Provider Demographics
NPI:1922374883
Name:PRIDE COMMUNITY SERVICES, INC.
Entity Type:Organization
Organization Name:PRIDE COMMUNITY SERVICES, INC.
Other - Org Name:PRIDE IN LOGAN COUNTY, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-752-6868
Mailing Address - Street 1:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-1346
Mailing Address - Country:US
Mailing Address - Phone:304-752-6868
Mailing Address - Fax:304-752-1047
Practice Address - Street 1:699 STRATTON ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4020
Practice Address - Country:US
Practice Address - Phone:304-752-2686
Practice Address - Fax:304-752-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810022733Medicaid