MEDICARE: WISHING WELL MANOR, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	59	WV
2	310400000X	Assisted Living Facility	132	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073501466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISHING WELL MANOR, INC.

Provider Business Mailing Address
First Line	:	1543 COUNTRY CLUB RD
Second Line	:
City	:	FAIRMONT
State	:	WV
Zip	:	26554-1306
Country	:	US
Telephone Number	:	304-366-8414
Fax Number	:	304-363-2384

Provider Business Practice Location Address
First Line	:	1543 COUNTRY CLUB RD
Second Line	:
City	:	FAIRMONT
State	:	WV
Zip	:	26554-1306
Country	:	US
Telephone Number	:	304-366-8414
Fax Number	:	304-363-2384

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MRS. CARLENE S. MOORE
Credential	:	NHA
Telephone Number	:	304-366-8414

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	09/11/2025

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Directions to “WISHING WELL MANOR, INC. ” Practice Location

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