Basic Information
| Provider Information | |||||||||
| NPI: | 1891871893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WARREN MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LYNN CARE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N SHENANDOAH AVE | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226303547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406360327 | ||||||||
| FaxNumber: | 5406360198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 N SHENANDOAH AVE | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226303547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406360327 | ||||||||
| FaxNumber: | 5406360198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER, INSURANCE CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5405360231 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | H1913 | VA | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 4953169 | 05 | VA | MEDICAID |