1790865962 NPI number — MONONGALIA HOME CORPORATION

Table of content: (NPI 1790865962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790865962 NPI number — MONONGALIA HOME CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONONGALIA HOME CORPORATION
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:
SUNDALE NURSING HOME
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:
1790865962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 J D ANDERSON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26505-3474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-599-0497
Provider Business Mailing Address Fax Number:
304-599-9083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 J D ANDERSON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-3474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-599-0497
Provider Business Practice Location Address Fax Number:
304-599-9083
Provider Enumeration Date:
10/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HICKS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
MANAGING AGENT
Authorized Official Telephone Number:
304-599-0497

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  23 , 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: 1790865962 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".