Basic Information
Provider Information | |||||||||
NPI: | 1568847606 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARTINSBURG CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLARY GROVE | ||||||||
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: | 209 CLOVER ST | ||||||||
Address2: |   | ||||||||
City: | MARTINSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 254043803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042638921 | ||||||||
FaxNumber: | 3042632548 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2015 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PACK | ||||||||
AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
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 | 52 | WV | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 314000000X | 52 | WV | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.