1396981064 NPI number — 1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC

Table of content: (NPI 1396981064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396981064 NPI number — 1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PIERPONT CENTER AT FAIRMONT CAMPUS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396981064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNETT SQUARE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19348-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-925-4436
Provider Business Mailing Address Fax Number:
610-347-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1543 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-363-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DROPESKEY
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATE DIRECTOR
Authorized Official Telephone Number:
610-925-4231

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  59 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810013993 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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