Provider Demographics
NPI:1386729036
Name:TRINITY HEALTH CARE SERVICES OF LOGAN INC
Entity type:Organization
Organization Name:TRINITY HEALTH CARE SERVICES OF LOGAN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:704-369-7200
Mailing Address - Street 1:2115 REXFORD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-3476
Mailing Address - Country:US
Mailing Address - Phone:704-369-7200
Mailing Address - Fax:704-362-0411
Practice Address - Street 1:1000 W PARK AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3155
Practice Address - Country:US
Practice Address - Phone:304-752-8723
Practice Address - Fax:304-752-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV86313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006016Medicaid
WV515140Medicare Oscar/Certification