Provider Demographics
NPI:1033546924
Name:STONEWALL HOME OXYGEN THERAPY, INC.
Entity Type:Organization
Organization Name:STONEWALL HOME OXYGEN THERAPY, INC.
Other - Org Name:SHOT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF EXTERNAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:EISENBEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-269-0100
Mailing Address - Street 1:456 MARKET PLACE MALL
Mailing Address - Street 2:SUITE A
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-6938
Mailing Address - Country:US
Mailing Address - Phone:304-269-0100
Mailing Address - Fax:304-269-4559
Practice Address - Street 1:456 MARKET PLACE MALL
Practice Address - Street 2:SUITE A
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-6938
Practice Address - Country:US
Practice Address - Phone:304-269-0100
Practice Address - Fax:304-269-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910001067Medicaid