Healthcare Provider Details

I. General information

NPI: 1912862590
Provider Name (Legal Business Name): MOUNTAINEER HOME MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 HONAKER AVE
PRINCETON WV
24740-3047
US

IV. Provider business mailing address

1411 HONAKER AVE
PRINCETON WV
24740-3047
US

V. Phone/Fax

Practice location:
  • Phone: 888-240-1030
  • Fax: 304-225-1115
Mailing address:
  • Phone: 888-240-1030
  • Fax: 304-225-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE JACKSON
Title or Position: COLLECTIONS MANAGER
Credential:
Phone: 304-225-6290