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Tug River Health Association, Inc.

Organization Active NPI Federally Qualified Health Center (FQHC) · Bradshaw, WV

NPI 1295033009 · NPPES record last updated Dec 12, 2011

Key facts

NPI
1295033009
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
TUG RIVER HEALTH ASSOCIATION, INC.
Practice address
512 Mountaineer Highway
Room 1344
Bradshaw, WV 24817-0000
Phone
(304) 967-7682
Fax
(304) 967-7684
NPI assigned
Mar 2, 2011
Organization subpart
No

Authorized official

Name
Tim A Crofton, MBA
Title
Ceo
Phone
(304) 448-2101

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs with the same Medicare PAC ID 5

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

Corporate family (same tax ID) 14

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

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 17

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

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in WV

Federally qualified health center certification: CCN 511973

Legal name
TUG RIVER HEALTH ASSOCIATION, INC
Doing business as
TUG RIVER RIVERVIEW WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 7, 2011
Last certification
Oct 7, 2011
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
Oct 7, 2011 in WV
Enrollment address
512 Mountaineer Highway
Room 1344
Bradshaw, WV 24817-0000

All disclosed owners & managing parties 10

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

NameRoleSinceShare
David Dunson
Individual 		Corporate Director Jul 29, 2011
Timothy a Crofton
Individual 		Corporate Director Mar 1, 2011
Operational/Managerial Control
Ceo		 Mar 1, 2011
Fred Odum
Individual 		Corporate Director Jul 29, 2011
Micheal Lushbaugh
Individual 		Corporate Director Jul 29, 2011
Lana Kibbey
Individual 		Corporate Director Jul 29, 2011
Tug River Health Association, Inc
Organization · Bradshaw, WV 		Operational/Managerial Control Mar 1, 2011
Sandra Shaw
Individual 		Corporate Director Jul 29, 2011
Mark Jones
Individual 		Corporate Director Jul 29, 2011
Clara L Thompson
Individual 		Corporate Director Jul 29, 2011
John Calloway
Individual 		Corporate Director Jul 29, 2011

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Tug River Health Association, Inc
Princeton, WV · CCN 581808		 Federally qualified health center 5% Or Greater Direct Ownership Interest Jan 1, 2000

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20110929000113 WV Part a Provider - Federally Qualified Health Center (FQHC) 7214820547 Practice locations: Bradshaw, WV
O20200213001912 WV Part B Supplier - Clinic/Group Practice 7214820547 Receives reassigned benefits from 16 practitioners
Practice locations: Bradshaw, WV

National Provider Directory

Tax ID family
Tug River Health Association Inc (15 organizations share this tax ID)

Locations

1880 Mount View Rd
Ste 500
Welch, WV 24801
Phone (304) 436-4798

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Yes

Addresses

Primary practice location

512 Mountaineer Highway
Room 1344
Bradshaw, WV 24817-0000

Mailing address

Route 103 Supply Street
PO Box 507
Gary, WV 24836-0507
Phone (304) 448-2101

Other identifiers

IdentifierTypeStateIssuer
3810021840MedicaidWV

Other names

  • Tug River/River View Wellness Center Other name

Other providers in Bradshaw, WV

All providers in Bradshaw, WV · Federally Qualified Health Center (FQHC) in West Virginia

Sources for this page

Verify at the official NPI Registry.