Provider Demographics
NPI:1992827604
Name:ST CHARLES HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:ST CHARLES HEALTH COUNCIL INC
Other - Org Name:COUNCIL FAMILY HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-546-5310
Mailing Address - Street 1:4124 COUNCIL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:HONAKER
Mailing Address - State:VA
Mailing Address - Zip Code:24260-4994
Mailing Address - Country:US
Mailing Address - Phone:276-859-0859
Mailing Address - Fax:276-546-9708
Practice Address - Street 1:ROUTE 80
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:VA
Practice Address - Zip Code:24239
Practice Address - Country:US
Practice Address - Phone:276-859-0859
Practice Address - Fax:276-859-0587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007602995Medicaid
VA491833Medicare Oscar/Certification
VAC06288Medicare PIN