Provider Demographics
NPI:1265605208
Name:MANCHIN CLINIC SOUTH, LLC
Entity type:Organization
Organization Name:MANCHIN CLINIC SOUTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-367-9170
Mailing Address - Street 1:181 MIDDLETOWN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-367-9170
Mailing Address - Fax:304-367-9180
Practice Address - Street 1:181 MIDDLETOWN LOOP
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:WV
Practice Address - Zip Code:26554-8703
Practice Address - Country:US
Practice Address - Phone:304-367-9170
Practice Address - Fax:304-367-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011616Medicaid
WV9375131Medicare PIN