1497752455 NPI number — PINE VIEW NURSING & CONVALESCENT HOME

Table of content: (NPI 1497752455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497752455 NPI number — PINE VIEW NURSING & CONVALESCENT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE VIEW NURSING & CONVALESCENT HOME
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:
PINE VIEW NURSING & REHABILITATION
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:
1497752455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 MCKINLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26362-1150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-643-2712
Provider Business Mailing Address Fax Number:
304-643-4979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MCKINLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26362-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-643-2712
Provider Business Practice Location Address Fax Number:
304-643-4979
Provider Enumeration Date:
07/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KIRK
Authorized Official First Name:
LYNDA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
SEC/TREAS
Authorized Official Telephone Number:
304-643-2712

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  19 , 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: 0003828000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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