Basic Information
| Provider Information | |||||||||
| NPI: | 1902802259 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUND VIEW HEALTH CARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 FLORAL ST | ||||||||
| Address2: | |||||||||
| City: | MOUNDSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260411293 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 3048431504 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 FLORAL ST | ||||||||
| Address2: | |||||||||
| City: | MOUNDSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260411293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048431035 | ||||||||
| FaxNumber: | 3048431504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOLGOVSKIJ | ||||||||
| AuthorizedOfficialFirstName: | KONSTANTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3048431035 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 75 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0003791000 | 05 | WV | MEDICAID |