1346947025 NPI number — ST. JOSEPH RECOVERY CENTER, LLC

Table of content: (NPI 1346947025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346947025 NPI number — ST. JOSEPH RECOVERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOSEPH RECOVERY CENTER, 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:
Provider Other Organization Name Type Code:
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:
1346947025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 MURDOCH AVE BLDG C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARKERSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26101-3230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-916-1881
Provider Business Mailing Address Fax Number:
304-974-0433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1073 ARBUCKLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26651-1745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-254-6159
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEADOWS
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
304-916-1881

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1174021406 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".