Healthcare Provider Details

I. General information

NPI: 1417931379
Provider Name (Legal Business Name): PENDLETON COMMUNITY CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16921 MOUNTAINEER DRIVE
RIVERTON WV
26814-0101
US

IV. Provider business mailing address

PO BOX 101
RIVERTON WV
26814-0101
US

V. Phone/Fax

Practice location:
  • Phone: 304-567-2101
  • Fax: 304-567-2102
Mailing address:
  • Phone: 304-567-2101
  • Fax: 304-567-2102

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 M HUDSON
Title or Position: CEO
Credential:
Phone: 304-358-7230