Provider Demographics
NPI:1104086503
Name:CHARLES W. CAMMACK CHILDREN'S CENTER, INC.
Entity type:Organization
Organization Name:CHARLES W. CAMMACK CHILDREN'S CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-523-3497
Mailing Address - Street 1:64 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1751
Mailing Address - Country:US
Mailing Address - Phone:304-523-3497
Mailing Address - Fax:304-529-3882
Practice Address - Street 1:64 6TH AVE W
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1751
Practice Address - Country:US
Practice Address - Phone:304-523-3497
Practice Address - Fax:304-529-3882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0023392002Medicaid