Healthcare Provider Details

I. General information

NPI: 1063906303
Provider Name (Legal Business Name): MOUNDSVILLE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FLORAL ST
MOUNDSVILLE WV
26041-1293
US

IV. Provider business mailing address

700 CHAPPELL RD
CHARLESTON WV
25304-2704
US

V. Phone/Fax

Practice location:
  • Phone: 304-843-1035
  • Fax: 304-843-1504
Mailing address:
  • Phone: 304-343-1950
  • Fax: 304-343-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE A PACK
Title or Position: MEMBER
Credential:
Phone: 304-343-1950