Provider Demographics
NPI:1205165347
Name:POTOMAC HIGHLANDS GUILD
Entity type:Organization
Organization Name:POTOMAC HIGHLANDS GUILD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A/R OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDRIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-257-1155
Mailing Address - Street 1:7 MOUNTAIN VIEW ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1796
Mailing Address - Country:US
Mailing Address - Phone:130-425-7115
Mailing Address - Fax:304-257-1945
Practice Address - Street 1:7 MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1796
Practice Address - Country:US
Practice Address - Phone:304-257-1555
Practice Address - Fax:304-257-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1036-8848251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005473000Medicaid
WV0005473002Medicaid
WV0005473001Medicaid
WV0005473000Medicaid