Healthcare Provider Details

I. General information

NPI: 1184807661
Provider Name (Legal Business Name): MOUNTAIN EMPIRE OLDER CITIZENS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 06/28/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 3RD AVE E
BIG STONE GAP VA
24219-3115
US

IV. Provider business mailing address

PO BOX 888 1-A INDUSTRIAL PARK ROAD
BIG STONE GAP VA
24219-0888
US

V. Phone/Fax

Practice location:
  • Phone: 276-523-4202
  • Fax: 276-523-4208
Mailing address:
  • Phone: 276-523-4202
  • Fax: 276-523-4208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL K WAMPLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 276-523-4202