Basic Information
| Provider Information | |||||||||
| NPI: | 1053635912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RSCR WEST VIRGINIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9901 LINN STATION RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402233808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008660860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1618 BUCKHANNON PIKE | ||||||||
| Address2: | |||||||||
| City: | NUTTER FORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263014465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043260140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 03/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | OMBRES | ||||||||
| AuthorizedOfficialFirstName: | DEENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRIVACY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5023942387 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 3810011260 | 05 | WV | MEDICAID |