Basic Information
Provider Information | |||||||||
NPI: | 1447233911 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PLEASANTS CAREHAVEN OPERATING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STONERISE BELMONT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 CHAPPELL RD | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253042704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043431950 | ||||||||
FaxNumber: | 3043431947 | ||||||||
Practice Location | |||||||||
Address1: | 506 RIVERVIEW DR | ||||||||
Address2: |   | ||||||||
City: | BELMONT | ||||||||
State: | WV | ||||||||
PostalCode: | 261349715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046652065 | ||||||||
FaxNumber: | 3046652613 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2005 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PACK | ||||||||
AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3043431950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 130 | WV | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 314000000X | 125 | WV | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 51E145 | 05 | WV |   | MEDICAID | 515191 | 01 |   | MEDICARE PROVIDER | OTHER |