Healthcare Provider Details

I. General information

NPI: 1043255433
Provider Name (Legal Business Name): HEARTLAND OF CLARKSBURG WV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PARKWAY DR
CLARKSBURG WV
26301-4357
US

IV. Provider business mailing address

333 N SUMMIT ST ATTN: BARRY LAZARUS
TOLEDO OH
43604-1531
US

V. Phone/Fax

Practice location:
  • Phone: 304-624-6401
  • Fax: 304-624-8026
Mailing address:
  • Phone: 419-252-5541
  • Fax: 419-252-5548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number79
License Number StateWV

VIII. Authorized Official

Name: MR. BARRY A LAZARUS
Title or Position: VICE PRESIDENT - REIMBURSEMENTS
Credential:
Phone: 419-252-5541