Healthcare Provider Details

I. General information

NPI: 1023612504
Provider Name (Legal Business Name): THREE RIVERS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 HINTON BYP
HINTON WV
25951-9184
US

IV. Provider business mailing address

158 HINTON BYP
HINTON WV
25951-9184
US

V. Phone/Fax

Practice location:
  • Phone: 304-309-4143
  • Fax: 304-309-4146
Mailing address:
  • Phone: 304-309-4143
  • Fax: 304-309-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLEY DAWN HUFFMAN
Title or Position: OFFICE MGR / PRESIDENT
Credential:
Phone: 304-309-4143