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General NPI Number Information
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NPI Number | 1073501466
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Entity Type | Organization
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Legal Business Name | WISHING WELL MANOR, INC.
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Dates
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Enumeration Date | 10/10/2005
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1543 COUNTRY CLUB RD
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City | FAIRMONT
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State | WV
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Zip | 26554-1306
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Country | US
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Telephone | 304-366-8414
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Fax | 304-363-2384
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Provider Business Mailing Address
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Address Line | 1543 COUNTRY CLUB RD
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City | FAIRMONT
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State | WV
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Zip | 26554-1306
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Country | US
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Telephone | 304-366-8414
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Fax | 304-363-2384
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Authorized Official
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Title or Position | CONTROLLER
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Name | MRS. CARLENE S. MOORE
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Credential | NHA
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Telephone | 304-366-8414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 59
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 132
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License Number State | WV
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