Provider Demographics
NPI:1073501466
Name:WISHING WELL MANOR, INC.
Entity Type:Organization
Organization Name:WISHING WELL MANOR, INC.
Other - Org Name:WISHING WELL MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:304-366-8414
Mailing Address - Street 1:1543 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1306
Mailing Address - Country:US
Mailing Address - Phone:304-366-8414
Mailing Address - Fax:304-363-2384
Practice Address - Street 1:1543 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1306
Practice Address - Country:US
Practice Address - Phone:304-366-8414
Practice Address - Fax:304-363-2384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV132310400000X
WV59314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003893000Medicaid
WV0003893000Medicaid