Healthcare Provider Details

I. General information

NPI: 1073501466
Provider Name (Legal Business Name): WISHING WELL MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 COUNTRY CLUB RD
FAIRMONT WV
26554-1306
US

IV. Provider business mailing address

1543 COUNTRY CLUB RD
FAIRMONT WV
26554-1306
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-8414
  • Fax: 304-363-2384
Mailing address:
  • Phone: 304-366-8414
  • Fax: 304-363-2384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number59
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number132
License Number StateWV

VIII. Authorized Official

Name: MRS. CARLENE S. MOORE
Title or Position: CONTROLLER
Credential: NHA
Phone: 304-366-8414