Basic Information
Provider Information | |||||||||
NPI: | 1841470069 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MORGANTOWN SNF ACQUISITION LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STONERISE MORGANTOWN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7500 MACCORKLE AVE SE | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253042935 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043431950 | ||||||||
FaxNumber: | 3043431947 | ||||||||
Practice Location | |||||||||
Address1: | 30 MON GENERAL DR | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265052853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882448160 | ||||||||
FaxNumber: | 3042852727 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2007 | ||||||||
LastUpdateDate: | 01/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUDSON | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | ACCOUNTANT | ||||||||
AuthorizedOfficialTelephone: | 3043431950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | WV | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.