Provider Demographics
NPI:1932288107
Name:7TH AVE CLINIC
Entity Type:Organization
Organization Name:7TH AVE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:304-673-1913
Mailing Address - Street 1:HC 74 BOX 284
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-9121
Mailing Address - Country:US
Mailing Address - Phone:394-673-1913
Mailing Address - Fax:304-466-1676
Practice Address - Street 1:623 TEMPLE ST
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951
Practice Address - Country:US
Practice Address - Phone:304-673-1913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV889103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPENDINGMedicaid