Healthcare Provider Details

I. General information

NPI: 1083324735
Provider Name (Legal Business Name): ST. MARY'S HEALTH WAGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5628 PATRIOT DRIVE
WISE VA
24293
US

IV. Provider business mailing address

PO BOX 7070
WISE VA
24293-7070
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-8850
  • Fax:
Mailing address:
  • Phone: 276-328-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAULA HILL
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 276-337-0331