Basic Information
| Provider Information | |||||||||
| NPI: | 1205025020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HP/STANDARDSVILLE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EVERGREENE NURSING CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 WILLIAM MILLS DR | ||||||||
| Address2: | |||||||||
| City: | STANARDSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229733055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349854434 | ||||||||
| FaxNumber: | 4349852499 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 WILLIAM MILLS DR | ||||||||
| Address2: | |||||||||
| City: | STANARDSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229733055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349854434 | ||||||||
| FaxNumber: | 4349852499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 07/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | MITTLEIDER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7706190866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2551 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.