Provider Demographics
NPI:1992889000
Name:TUG RIVER HEALTH ASSOCIATION, INC
Entity type:Organization
Organization Name:TUG RIVER HEALTH ASSOCIATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CROFTON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:304-448-2101
Mailing Address - Street 1:ROUTE 103 SUPPLY STREET, PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836
Mailing Address - Country:US
Mailing Address - Phone:304-448-2101
Mailing Address - Fax:304-448-3217
Practice Address - Street 1:10 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORTHFORK
Practice Address - State:WV
Practice Address - Zip Code:24868
Practice Address - Country:US
Practice Address - Phone:304-862-2588
Practice Address - Fax:304-862-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV031000261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6705105000Medicaid