Provider Demographics
NPI:1043207731
Name:BRAXTON HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:BRAXTON HEALTH CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:DRAZDIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-765-2861
Mailing Address - Street 1:859 DAYS DR
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:WV
Mailing Address - Zip Code:26601-6255
Mailing Address - Country:US
Mailing Address - Phone:304-765-2861
Mailing Address - Fax:304-765-2863
Practice Address - Street 1:859 DAYS DR
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:WV
Practice Address - Zip Code:26601-6255
Practice Address - Country:US
Practice Address - Phone:304-765-2861
Practice Address - Fax:304-765-2863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0004097000Medicaid
WV515180Medicare Oscar/Certification