Healthcare Provider Details

I. General information

NPI: 1972936482
Provider Name (Legal Business Name): EASTBROOK CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3819 CHESTERFIELD AVE
CHARLESTON WV
25304-2647
US

IV. Provider business mailing address

700 CHAPPELL RD
CHARLESTON WV
25304-2704
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-4771
  • Fax: 304-925-1343
Mailing address:
  • Phone: 304-343-1950
  • Fax: 304-343-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number65
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE A PACK
Title or Position: OWNER/MANAGER
Credential:
Phone: 304-343-1950