Provider Demographics
NPI:1669411914
Name:CHASE CITY PRIMARY CARE CENTER, LLC
Entity type:Organization
Organization Name:CHASE CITY PRIMARY CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE & CFO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBBY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:434-774-2400
Mailing Address - Street 1:200 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHASE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:23924-1456
Mailing Address - Country:US
Mailing Address - Phone:434-372-0900
Mailing Address - Fax:434-372-8681
Practice Address - Street 1:200 E 5TH ST
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-1456
Practice Address - Country:US
Practice Address - Phone:434-372-0900
Practice Address - Fax:434-372-8681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010288134Medicaid
VA010288134Medicaid
VA498906Medicare PIN