Provider Demographics
NPI:1003419169
Name:MONGOLD, EILEEN ROSALEE
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:ROSALEE
Last Name:MONGOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 RIDGETOP DR
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-8947
Mailing Address - Country:US
Mailing Address - Phone:304-703-2419
Mailing Address - Fax:
Practice Address - Street 1:422 RIDGETOP DR
Practice Address - Street 2:
Practice Address - City:MOOREFIELD
Practice Address - State:WV
Practice Address - Zip Code:26836-8947
Practice Address - Country:US
Practice Address - Phone:304-703-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant