Healthcare Provider Details

I. General information

NPI: 1417963000
Provider Name (Legal Business Name): WVDHHR JOHN MANCHIN SR HEALTH CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 GUFFEY STREET
FAIRMONT WV
26554
US

IV. Provider business mailing address

401 GUFFEY STREET
FAIRMONT WV
26554
US

V. Phone/Fax

Practice location:
  • Phone: 304-363-2500
  • Fax: 304-363-0263
Mailing address:
  • Phone: 304-363-2500
  • Fax: 304-363-0263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROL D MERRILL
Title or Position: CEO ADMINISTRATOR
Credential: NHA
Phone: 304-363-2500