Healthcare Provider Details

I. General information

NPI: 1750364139
Provider Name (Legal Business Name): PENDLETON MANOR INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 GOOD SAMARITAN DRIVE
FRANKLIN WV
26807-0700
US

IV. Provider business mailing address

PO BOX 700 68 GOOD SAMARIAN DRIVE
FRANKLIN WV
26807-0700
US

V. Phone/Fax

Practice location:
  • Phone: 304-358-2322
  • Fax: 304-358-2334
Mailing address:
  • Phone: 304-358-2322
  • Fax: 304-358-2334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number66
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDALL KROPP
Title or Position: ADMINISTRATOR
Credential:
Phone: 304-358-2322