Basic Information
Provider Information | |||||||||
NPI: | 1609931278 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RESCARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VOCA | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1560 | ||||||||
Address2: |   | ||||||||
City: | PRINCETON | ||||||||
State: | WV | ||||||||
PostalCode: | 247401560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044870788 | ||||||||
FaxNumber: | 3044872455 | ||||||||
Practice Location | |||||||||
Address1: | BROWNINGS ADDITION | ||||||||
Address2: |   | ||||||||
City: | ACCOVILLE | ||||||||
State: | WV | ||||||||
PostalCode: | 25606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045837615 | ||||||||
FaxNumber: | 3045837614 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STREET | ||||||||
AuthorizedOfficialFirstName: | LENA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3045838675 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 346 | WV | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
ID Information
ID | Type | State | Issuer | Description | 0005258021 | 05 | WV |   | MEDICAID |