Basic Information
| Provider Information | |||||||||
| NPI: | 1720281975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PLEASANT VALLEY NURSING AND REHABILITATION CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PLEASANT VALLEY NURSE CARE CEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255502163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046755236 | ||||||||
| FaxNumber: | 3046752805 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255502163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046755236 | ||||||||
| FaxNumber: | 3046752805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILLILAND | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3046754340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 06 | WV | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 06 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000324425 | 01 | WV | BCBS | OTHER | 55044008603 | 01 | WV | WORKERS COMPENSATION | OTHER | 0001300001 | 05 | WV | MEDICAID |