Healthcare Provider Details

I. General information

NPI: 1205243961
Provider Name (Legal Business Name): PENDLETON COMMUNITY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 MAPLE AVE
FRANKLIN WV
26807-0040
US

IV. Provider business mailing address

PO BOX 100
FRANKLIN WV
26807-0100
US

V. Phone/Fax

Practice location:
  • Phone: 304-358-3254
  • Fax:
Mailing address:
  • Phone: 304-358-2355
  • Fax:

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: JAMIE HUDSON
Title or Position: CEO
Credential:
Phone: 304-358-2355