MEDICARE: MOUNDSVILLE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1063906303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNDSVILLE CENTER LLC

Provider Business Mailing Address
First Line	:	700 CHAPPELL RD
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-2704
Country	:	US
Telephone Number	:	304-343-1950
Fax Number	:	304-343-1947

Provider Business Practice Location Address
First Line	:	2200 FLORAL ST
Second Line	:
City	:	MOUNDSVILLE
State	:	WV
Zip	:	26041-1293
Country	:	US
Telephone Number	:	304-843-1035
Fax Number	:	304-843-1504

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. LAWRENCE A PACK
Credential	:
Telephone Number	:	304-343-1950

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	05/18/2022

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