Provider Demographics
NPI:1811664378
Name:WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC
Entity type:Organization
Organization Name:WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-275-3301
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:WV
Mailing Address - Zip Code:26143-0609
Mailing Address - Country:US
Mailing Address - Phone:304-275-3301
Mailing Address - Fax:304-275-4798
Practice Address - Street 1:2101 DUDLEY AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3462
Practice Address - Country:US
Practice Address - Phone:304-917-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty