NPIMap

Organization Active NPI

Clinch River Health Services Inc

Doing business as Clinch River Health Services

  • Federally Qualified Health Center (FQHC)
  • Dungannon, VA
National Provider Identifier
1558653741
Registry record updated Feb 25, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CLINCH RIVER HEALTH SERVICES INC
Doing business as
Clinch River Health Services
Practice address
17285 Veterans Memorial Hwy
Dungannon, VA 24245
Phone
(276) 467-2201
Fax
(276) 467-2673
NPI assigned
May 6, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 25, 2022

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

Authorized official

Name
Gary GilliamNPI 1154704708
Title
Executive Director
Phone
(276) 467-2201

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

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

Addresses

Primary practice location

17285 Veterans Memorial Hwy
Dungannon, VA 24245

Mailing address

PO Box 4710
Glen Allen, VA 23058-4710
Phone (804) 237-7690

Other names 1

  • Clinch River Health Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050113000430 VA Part B Supplier - Clinic/Group Practice 6709835002 Receives reassigned benefits from 11 practitioners
1 other NPI on this enrollment
Practice locations: Dungannon, VA
O20050310000468 VA Part A Provider - Federally Qualified Health Center (FQHC) 6709835002 1 other NPI on this enrollment
Practice locations: Dungannon, VA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1558653741. Details of each certification follow.

Federally qualified health center certification: CCN 491824

Legal name
CLINCH RIVER HEALTH SERVICES INC
Doing business as
CLINCH RIVER HEALTH SERVICES INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 22, 1976 in VA
Enrollment address
17285 Veterans Memorial Hwy
Dungannon, VA 24245-3937

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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
49D0684301Clinch River Health Services Inc17285 Veterans Memorial Highway, Dungannon, VA 24245Provider-performed microscopyMar 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
Clinch River Health Serv2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Noah Jennings Individual Corporate Director Nov 1, 2007
Gary W Gilliam Individual Corporate DirectorExecutive Director Aug 1, 2021
W-2 Managing EmployeeExecutive Director Aug 1, 2021
Operational/Managerial ControlExecutive Director Aug 1, 2021
Danny Mann Individual Corporate Director Nov 1, 2007

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1304640000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645747200000",
    "number": "1558653741",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 4710",
            "city": "GLEN ALLEN",
            "state": "VA",
            "postal_code": "230584710",
            "telephone_number": "804-237-7690"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17285 VETERANS MEMORIAL HWY",
            "city": "DUNGANNON",
            "state": "VA",
            "postal_code": "24245",
            "telephone_number": "276-467-2201",
            "fax_number": "276-467-2673"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLINCH RIVER HEALTH SERVICES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-06",
        "last_updated": "2022-02-25",
        "certification_date": "2022-02-25",
        "status": "A",
        "authorized_official_last_name": "GILLIAM",
        "authorized_official_first_name": "GARY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "276-467-2201"
    },
    "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": "Clinch River Health Services",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Clinch River Health Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dungannon, VA

Sources for this page

Verify at the official NPI Registry.