Provider Demographics
NPI:1063511731
Name:CORTLAND ACRES ASSOCIATION INC.
Entity Type:Organization
Organization Name:CORTLAND ACRES ASSOCIATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLEVENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-463-4181
Mailing Address - Street 1:39 CORTLAND ACRES LN
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:WV
Mailing Address - Zip Code:26292-8018
Mailing Address - Country:US
Mailing Address - Phone:304-463-4181
Mailing Address - Fax:304-463-4190
Practice Address - Street 1:39 CORTLAND ACRES LN
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:WV
Practice Address - Zip Code:26292-8018
Practice Address - Country:US
Practice Address - Phone:304-463-4181
Practice Address - Fax:304-463-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV74313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003124000Medicaid
WV001706329OtherMT. STATE BC BS
WV0158279000Medicaid
WV515063Medicare Oscar/Certification