Basic Information
| Provider Information | |||||||||
| NPI: | 1386037331 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BERKELEY SPRINGS CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STONERISE BERKELEY SPRINGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7500 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253042935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043431950 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 456 AUTUMN ACRES RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254113202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042583673 | ||||||||
| FaxNumber: | 3042586618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2015 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PACK | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3043431950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 55 | WV | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 55 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.