Basic Information
| Provider Information | |||||||||
| NPI: | 1396981064 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PIERPONT CENTER AT FAIRMONT CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254436 | ||||||||
| FaxNumber: | 6103474099 | ||||||||
| Practice Location | |||||||||
| Address1: | 1543 COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265541306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043632273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | DROPESKEY | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6109254231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 59 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3810013993 | 05 | WV | MEDICAID |