Healthcare Provider Details

I. General information

NPI: 1609092477
Provider Name (Legal Business Name): STONEBROOK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3273 CHARLES TOWN RD
KEARNEYSVILLE WV
25430-2649
US

IV. Provider business mailing address

PO BOX 70
KEARNEYSVILLE WV
25430-0070
US

V. Phone/Fax

Practice location:
  • Phone: 304-267-2763
  • Fax: 304-267-1514
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number36
License Number StateWV

VIII. Authorized Official

Name: JOHN W FANNING
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 304-267-2763