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General NPI Number Information
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NPI Number | 1588908362
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Entity Type | Organization
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Legal Business Name | CABIN CREEK HEALTH CENTER, INC.
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Dates
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Enumeration Date | 11/19/2012
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Last Update Date | 11/19/2012
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Provider Practice Location Address
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Address Line | 4602 MACCORKLE AVE SE
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City | CHARLESTON
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State | WV
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Zip | 25304-1848
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Country | US
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Telephone | 304-734-2040
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Fax | 304-734-2047
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Provider Business Mailing Address
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Address Line | PO BOX 70
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City | DAWES
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State | WV
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Zip | 25054-0070
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Country | US
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Telephone | 304-734-2040
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Fax | 304-734-2047
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Authorized Official
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Title or Position | ADMINISTRATIVE ASSISTANT
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Name | JENNIFER RUSSELL
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Credential |
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Telephone | 304-734-2040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number | 1041-6374
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License Number State | WV
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