Basic Information
| Provider Information | |||||||||
| NPI: | 1548534464 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STANDARDSVILLE HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRACE HEALTH AND REHAB OF GREENE COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 02/24/2012 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARK DANKS | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4233081845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2551 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4953436 | 05 | VA | MEDICAID |