Healthcare Provider Details

I. General information

NPI: 1053668996
Provider Name (Legal Business Name): ST CHARLES HEALTH COUNCIL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10953 RIVERSIDE DRIVE
OAKWOOD VA
24631
US

IV. Provider business mailing address

1060 ANCHORAGE CIR
VANSANT VA
24656-7021
US

V. Phone/Fax

Practice location:
  • Phone: 276-498-1631
  • Fax: 276-498-1042
Mailing address:
  • Phone: 276-498-1625
  • Fax: 276-546-9704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MALCOLM PERDUE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 276-546-5310