Provider Demographics
NPI:1952423667
Name:ST CHARLES HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:ST CHARLES HEALTH COUNCIL INC
Other - Org Name:HAYSI CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MALCOM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-865-5121
Mailing Address - Street 1:102 OQUINN DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAYSI
Mailing Address - State:VA
Mailing Address - Zip Code:24256
Mailing Address - Country:US
Mailing Address - Phone:276-865-5121
Mailing Address - Fax:276-865-5652
Practice Address - Street 1:102 OQUINN DRIVE
Practice Address - Street 2:
Practice Address - City:HAYSI
Practice Address - State:VA
Practice Address - Zip Code:24256
Practice Address - Country:US
Practice Address - Phone:276-865-5121
Practice Address - Fax:276-865-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA491829Medicare ID - Type Unspecified
VA491829Medicare Oscar/Certification
VAC06889Medicare PIN