Healthcare Provider Details

I. General information

NPI: 1437199742
Provider Name (Legal Business Name): CABIN CREEK HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 KOONTZ AVE. SUITE 200
CLENDENIN WV
25045
US

IV. Provider business mailing address

107 KOONTZ AVE. SUITE 200
CLENDENIN WV
25045
US

V. Phone/Fax

Practice location:
  • Phone: 304-548-4900
  • Fax:
Mailing address:
  • Phone: 304-548-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number031820
License Number StateWV

VIII. Authorized Official

Name: CRAIG H. ROBINSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MPH
Phone: 304-734-2040