Provider Demographics
NPI:1588717219
Name:PCH EXPRESS CARE CLINIC
Entity type:Organization
Organization Name:PCH EXPRESS CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-694-8678
Mailing Address - Street 1:18688 JEB STUART HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-1559
Mailing Address - Country:US
Mailing Address - Phone:276-694-3151
Mailing Address - Fax:276-694-8655
Practice Address - Street 1:18688 JEB STUART HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171-1559
Practice Address - Country:US
Practice Address - Phone:276-694-3151
Practice Address - Fax:276-694-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1919261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA330049OtherMAMSI
VA146602OtherANTHEM
VA010135583Medicaid
VA010135583Medicaid
VA010135583Medicaid