Healthcare Provider Details

I. General information

NPI: 1215097613
Provider Name (Legal Business Name): BROADDUS HOSPITAL ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#5 HEALTHCARE DRIVE MANSFIELD HILL
PHILIPPI WV
26416
US

IV. Provider business mailing address

#5 HEALTHCARE DRIVE P.O. BOX 930
PHILIPPI WV
26416
US

V. Phone/Fax

Practice location:
  • Phone: 304-457-8535
  • Fax: 304-457-1516
Mailing address:
  • Phone: 304-457-8535
  • Fax: 304-457-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number96
License Number StateWV

VIII. Authorized Official

Name: MRS. DANA L. GOULD
Title or Position: CEO
Credential:
Phone: 304-457-1760