Provider Demographics
NPI:1063818599
Name:MOUNTAINEER HOME HEALTHCARE AGENCY, LLC
Entity Type:Organization
Organization Name:MOUNTAINEER HOME HEALTHCARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUSTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-799-6689
Mailing Address - Street 1:4614 PROSPECT AVE
Mailing Address - Street 2:421
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4394
Mailing Address - Country:US
Mailing Address - Phone:216-881-5588
Mailing Address - Fax:216-881-5995
Practice Address - Street 1:4614 PROSPECT AVE
Practice Address - Street 2:421
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4394
Practice Address - Country:US
Practice Address - Phone:216-881-5588
Practice Address - Fax:216-881-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health