Provider Demographics
NPI:1558447805
Name:LITTLE BEAVER FAMILY CLINIC
Entity type:Organization
Organization Name:LITTLE BEAVER FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:304-742-3570
Mailing Address - Street 1:PO BOX 1728
Mailing Address - Street 2:
Mailing Address - City:CRAIGSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26205-1728
Mailing Address - Country:US
Mailing Address - Phone:304-742-3570
Mailing Address - Fax:304-742-3572
Practice Address - Street 1:16130 WEBSTER RD.
Practice Address - Street 2:
Practice Address - City:CRAIGSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26205-1728
Practice Address - Country:US
Practice Address - Phone:304-742-3570
Practice Address - Fax:304-742-3572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001784453OtherMTN STATE BCBS
WV3810001807Medicaid
WVDE7201OtherRR MCARE
WVLI9359261Medicare ID - Type Unspecified
WVDE7201OtherRR MCARE