Healthcare Provider Details

I. General information

NPI: 1528381746
Provider Name (Legal Business Name): JACKSON COUNTY DEVELOPMENTAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 JACK BURLINGAME DR
MILLWOOD WV
25262-8576
US

IV. Provider business mailing address

270 JACK BURLINGAME DR
MILLWOOD WV
25262-8576
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-9311
  • Fax: 304-273-5131
Mailing address:
  • Phone: 304-273-9311
  • Fax: 304-273-5131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number406
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number406
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number406
License Number StateWV

VIII. Authorized Official

Name: MR. CRAIG ALAN GREENING
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 304-273-9311