Healthcare Provider Details

I. General information

NPI: 1043401730
Provider Name (Legal Business Name): WIRT COUNTY HEALTH SERVICES ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512A SOUTH CHURCH STREET
RIPLEY WV
25271-9710
US

IV. Provider business mailing address

PO BOX 609
ELIZABETH WV
26143-0609
US

V. Phone/Fax

Practice location:
  • Phone: 304-372-1033
  • Fax: 304-372-0223
Mailing address:
  • Phone: 304-275-3301
  • Fax: 304-275-4798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VICKI L. KNICELY
Title or Position: BILLING/CREDENTIALING SUPERVISOR
Credential:
Phone: 304-275-3301