Basic Information
| Provider Information | |||||||||
| NPI: | 1508254319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRD | ||||||||
| FirstName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3573 SLEEPY HOLLOW DR | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044371033 | ||||||||
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| Practice Location | |||||||||
| Address1: | 590 NORTH POPLAR FORK RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047577826 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2014 | ||||||||
| LastUpdateDate: | 12/31/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 51658 | WV | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 51658 | 01 | WV | RN BOARD | OTHER |