Provider Demographics
NPI:1942523931
Name:LINCOLN COUNTY PRIMARY CARE CENTER, INC.
Entity Type:Organization
Organization Name:LINCOLN COUNTY PRIMARY CARE CENTER, INC.
Other - Org Name:SOUTHERN WEST VIRIGNIA HEALTH SYSTEM-GILBERT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-824-5806
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5885
Practice Address - Street 1:202 LARRY JOE HARLESS DRIVE
Practice Address - Street 2:SUITE 205
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621-1842
Practice Address - Country:US
Practice Address - Phone:304-664-6270
Practice Address - Fax:304-664-6272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810019387Medicaid
WV5119531Medicare PIN
WV3810019387Medicaid