Healthcare Provider Details

I. General information

NPI: 1407259062
Provider Name (Legal Business Name): CLENDENIN HEALTH CENTER LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 KOONTZ AVE STE 200
CLENDENIN WV
25045-9581
US

IV. Provider business mailing address

PO BOX 70
DAWES WV
25054-0070
US

V. Phone/Fax

Practice location:
  • Phone: 304-734-2040
  • Fax: 301-734-2047
Mailing address:
  • Phone: 304-734-2040
  • Fax: 304-734-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER RUSSELL
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 304-734-2040