NPIMap

Organization Active NPI

Tug River Health Association, Inc.

  • Federally Qualified Health Center (FQHC)
  • Bradshaw, WV
National Provider Identifier
1295033009
Registry record updated Dec 12, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Dec 12, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2011

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

Authorized official

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

Specialties & licenses 1

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

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 names 1

  • Tug River/River View Wellness Center Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV2 enrollments

Enrollment records 2

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1295033009. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Oct 7, 2011 in WV
Enrollment address
512 Mountaineer Highway
Room 1344
Bradshaw, WV 24817-0000

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory
Tax ID family
Tug River Clinic15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

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

View all 14

Ownership & related parties

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 ControlCeo 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

Owners & managing parties with NPI records 5

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

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, IncPrinceton, WV, CCN 581808 Federally qualified health center 5% Or Greater Direct Ownership Interest Jan 1, 2000

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1299024000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1323648000000",
    "number": "1295033009",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "ROUTE 103 SUPPLY STREET",
            "address_2": "PO BOX 507",
            "city": "GARY",
            "state": "WV",
            "postal_code": "248360507",
            "telephone_number": "304-448-2101",
            "fax_number": "304-448-3217"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "512 MOUNTAINEER HIGHWAY",
            "address_2": "ROOM 1344",
            "city": "BRADSHAW",
            "state": "WV",
            "postal_code": "248170000",
            "telephone_number": "304-967-7682",
            "fax_number": "304-967-7684"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TUG RIVER HEALTH ASSOCIATION, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-02",
        "last_updated": "2011-12-12",
        "status": "A",
        "authorized_official_last_name": "CROFTON",
        "authorized_official_first_name": "TIM",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "304-448-2101",
        "authorized_official_credential": "MBA"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tug River/River View Wellness Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Bradshaw, WV

Sources for this page

Verify at the official NPI Registry.