Provider Demographics
NPI:1679695316
Name:ST. CHARLES HEALTH COUNCIL INC
Entity type:Organization
Organization Name:ST. CHARLES HEALTH COUNCIL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MALCOM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-475-5116
Mailing Address - Street 1:306 SOUTH SHADY AVENUE
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:VA
Mailing Address - Zip Code:24236
Mailing Address - Country:US
Mailing Address - Phone:276-475-5116
Mailing Address - Fax:276-475-5665
Practice Address - Street 1:306 SOUTH SHADY AVENUE
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:VA
Practice Address - Zip Code:24236
Practice Address - Country:US
Practice Address - Phone:276-475-5116
Practice Address - Fax:276-475-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007603002Medicaid
VA007603002Medicaid
491843Medicare ID - Type Unspecified
VA491843Medicare Oscar/Certification