Basic Information
| Provider Information | |||||||||
| NPI: | 1578983417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CABELL HEALTH CARE CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 532 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253220532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043441623 | ||||||||
| FaxNumber: | 3043445853 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 CAPITOL ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253012221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043441623 | ||||||||
| FaxNumber: | 3043445853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2014 | ||||||||
| LastUpdateDate: | 04/18/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAINTER | ||||||||
| AuthorizedOfficialFirstName: | TAMMY JO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3043441623 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 6 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.