Healthcare Provider Details

I. General information

NPI: 1801283882
Provider Name (Legal Business Name): MINGO COUNTY FAMILY WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 ROUTE 65
WILLIAMSON WV
25661-7497
US

IV. Provider business mailing address

872 ROUTE 65
WILLIAMSON WV
25661-7497
US

V. Phone/Fax

Practice location:
  • Phone: 304-475-3700
  • Fax: 304-475-3780
Mailing address:
  • Phone: 304-475-3700
  • Fax: 304-475-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AIMEE MICHELLE COLEGROVE
Title or Position: PRESIDENT/HEALTHCARE PROVIDER
Credential: NP
Phone: 304-475-3700