Basic Information
| Provider Information | |||||||||
| NPI: | 1164421756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEADOWVIEW MANOR HEALTH CARE CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 CRESTVIEW TER | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263301010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048427101 | ||||||||
| FaxNumber: | 3048427104 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 CRESTVIEW TER | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263301010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048427101 | ||||||||
| FaxNumber: | 3048427104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | TRACI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3048427101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 104 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0004114000 | 05 | WV | MEDICAID |