Provider Demographics
NPI:1003001215
Name:DAVITA OF GREENBRIER
Entity Type:Organization
Organization Name:DAVITA OF GREENBRIER
Other - Org Name:GAMBRO HEALTHCARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:FACILITY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:304-645-4806
Mailing Address - Street 1:129 SENECA TRL
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1564
Mailing Address - Country:US
Mailing Address - Phone:304-645-4806
Mailing Address - Fax:304-647-3941
Practice Address - Street 1:129 SENECA TRL
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1564
Practice Address - Country:US
Practice Address - Phone:304-645-4806
Practice Address - Fax:304-647-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV030330251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005742000Medicaid