NPIMap

Organization Active NPI

Lincoln County Primary Care Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Alum Creek, WV
National Provider Identifier
1003274580
Registry record updated Oct 2, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
2317-5033 Issued in WV
Legal business name
LINCOLN COUNTY PRIMARY CARE CENTER, INC
Practice address
267 Midway Rd
Alum Creek, WV 25003-9591
Phone
(304) 756-1007
Fax
(304) 756-1010
NPI assigned
Jan 29, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 2, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lisa Leach
Title
Ceo
Phone
(304) 824-5806

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 2317-5033 WV Primary

Addresses

Primary practice location

267 Midway Rd
Alum Creek, WV 25003-9591

Mailing address

7400 Lynn Ave
Hamlin, WV 25523-1138
Phone (304) 824-5806

Other identifiers 1

IdentifierTypeStateIssuer
1003274580MedicaidWV

Other names 1

  • Mustang Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160714002531 WV Part A Provider - Federally Qualified Health Center (FQHC) 6204821879 Practice locations: Alum Creek, WV

Federally qualified health center certification: CCN 511103

Legal name
LINCOLN COUNTY PRIMARY CARE CENTER INC
Doing business as
MUSTANG HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 6, 2016
Last certification
Jun 6, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 30, 1975 in WV
Enrollment address
267 Midway Rd
Alum Creek, WV 25003-9591

Other NPIs with the same Medicare PAC ID 24

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 24

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
51D2110088Mustang Health Center267 Midway Road, Alum Creek, WV 25003Certificate of waiverMar 7, 2028

National Provider Directory

National Provider Directory
Tax ID family
Man Rexcellence Program22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

Organizations that report the same tax identification number in the National Provider Directory.

View all 21

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Audrey Robinette Individual Corporate DirectorBoard Member Jul 1, 2020
Brian Vance Individual Corporate DirectorBoard Member Jul 1, 2020
Debrina Williams Individual Corporate DirectorBoard Member Jul 1, 2023
Letitia Weaver-Scites Individual Operational/Managerial ControlCredentialing Coordinator Apr 11, 2012
Lisa Leach Individual Operational/Managerial ControlInterim Ceo Mar 31, 2018
David Boggess Individual Corporate DirectorBoard Member Jul 1, 2018
Ronald McGrady Individual Operational/Managerial ControlAccountant/2ND DO Mar 8, 2012
Nancy Godby Individual Corporate DirectorBoard Member Jul 1, 2018
Priscilla Byrnside Individual Corporate Director Jul 1, 2020
Christy Laxton Individual Corporate DirectorBoard Member Jul 1, 2023
Lori Huffman Individual Corporate DirectorBoard Memeber Jul 1, 2020
Karl Melkus Individual Corporate DirectorBoard Member Jul 1, 2023
Dana Snyder Individual Corporate DirectorBoard Member Jul 1, 2020

Practitioners & affiliated clinicians

Practitioners 40

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 40

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1454025600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1538438400000",
    "number": "1003274580",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7400 LYNN AVE",
            "city": "HAMLIN",
            "state": "WV",
            "postal_code": "255231138",
            "telephone_number": "304-824-5806",
            "fax_number": "304-824-5885"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "267 MIDWAY RD",
            "city": "ALUM CREEK",
            "state": "WV",
            "postal_code": "250039591",
            "telephone_number": "304-756-1007",
            "fax_number": "304-756-1010"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LINCOLN COUNTY PRIMARY CARE CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-29",
        "last_updated": "2018-10-02",
        "status": "A",
        "authorized_official_last_name": "LEACH",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "304-824-5806"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WV",
            "license": "2317-5033",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1003274580",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mustang Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mustang Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Alum Creek, WV

Sources for this page

Verify at the official NPI Registry.