Provider Demographics
NPI:1205824646
Name:GLENWOOD PARK, INC.
Entity Type:Organization
Organization Name:GLENWOOD PARK, INC.
Other - Org Name:GLENWOOD PARK RETIREMENT VILLAGE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO / PRESIDENT / ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CNHA
Authorized Official - Phone:304-425-8128
Mailing Address - Street 1:1924 GLENWOOD PARK RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-7969
Mailing Address - Country:US
Mailing Address - Phone:304-425-8128
Mailing Address - Fax:304-487-1338
Practice Address - Street 1:1924 GLENWOOD PARK RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-7969
Practice Address - Country:US
Practice Address - Phone:304-425-8128
Practice Address - Fax:304-487-1338
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
WV4314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003502000Medicaid
WV0003502000Medicaid