Healthcare Provider Details

I. General information

NPI: 1356007785
Provider Name (Legal Business Name): MOUNTAINEER HOME MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 PARK ST
CUMBERLAND MD
21502-3172
US

IV. Provider business mailing address

5000 GREENBAG RD STE F6
MORGANTOWN WV
26501-7123
US

V. Phone/Fax

Practice location:
  • Phone: 240-410-1170
  • Fax: 240-362-7089
Mailing address:
  • Phone: 304-225-6290
  • Fax: 304-225-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE JACKSON
Title or Position: BILLING MANAGER
Credential:
Phone: 304-225-6290