Basic Information
| Provider Information | |||||||||
| NPI: | 1164410775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY HAVEN GERIATRIC CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | RD#2 BOX 44 | ||||||||
| Address2: | |||||||||
| City: | WELLSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260709505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043945322 | ||||||||
| FaxNumber: | 3043941242 | ||||||||
| Practice Location | |||||||||
| Address1: | RD#2 BOX 44 | ||||||||
| Address2: | |||||||||
| City: | WELLSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260709505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043945322 | ||||||||
| FaxNumber: | 3043941242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT-ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3043945322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VALLEY HAVEN GERIATRIC CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 113 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0003883000 | 05 | WV | MEDICAID |