MEDICARE: COUNCIL OF THE SOUTHERN MOUNTAINS, WV BRANCH, MCDOWELL CO CHAPTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	3810005980	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225114184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNCIL OF THE SOUTHERN MOUNTAINS, WV BRANCH, MCDOWELL CO CHAPTER, INC

Provider Business Mailing Address
First Line	:	PO BOX 85
Second Line	:
City	:	NORTHFORK
State	:	WV
Zip	:	24868-0085
Country	:	US
Telephone Number	:	304-862-3144
Fax Number	:	304-862-3071

Provider Business Practice Location Address
First Line	:	69 MAIN STREET
Second Line	:	CITY OF KEYSTONE BUILDING
City	:	KEYSTONE
State	:	WV
Zip	:	24868-0085
Country	:	US
Telephone Number	:	304-862-3144
Fax Number	:	304-862-3071

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	RANDAL JOHNSON
Credential	:	M.A.
Telephone Number	:	304-862-3144

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	08/22/2020

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