Healthcare Provider Details

I. General information

NPI: 1710104260
Provider Name (Legal Business Name): ST CHARLES HEALTH COUNCIL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 DANTE ROAD
ST PAUL VA
24283
US

IV. Provider business mailing address

CLINIC DRIVE HIGHWAY 63 NORTH
ST PAUL VA
24283
US

V. Phone/Fax

Practice location:
  • Phone: 276-762-0770
  • Fax: 276-762-0678
Mailing address:
  • Phone: 276-762-0770
  • Fax: 276-762-0678

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: CEO
Credential:
Phone: 276-546-5310