=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811081821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAINELLE MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 458 GREENBRIER STREET
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-438-6188
-----------------------------------------------------
Fax | 304-438-4037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 176 MEDICAL CENTER DR
-----------------------------------------------------
City | RAINELLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25962-1064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-438-6188
-----------------------------------------------------
Fax | 304-438-4037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | DEBRA J BENNETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-438-6188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 054272
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------