Provider Demographics
NPI:1225263932
Name:CORTLAND ACRES ASSOCIATION, INC.
Entity Type:Organization
Organization Name:CORTLAND ACRES ASSOCIATION, INC.
Other - Org Name:CORTLAND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-463-4181
Mailing Address - Street 1:HC 60 BOX 98
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:WV
Mailing Address - Zip Code:26292-9704
Mailing Address - Country:US
Mailing Address - Phone:304-463-4181
Mailing Address - Fax:304-463-4190
Practice Address - Street 1:HC 60 BOX 98
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:WV
Practice Address - Zip Code:26292-9704
Practice Address - Country:US
Practice Address - Phone:304-463-4181
Practice Address - Fax:304-463-4190
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORTLAND ACRES ASSOCIATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV74261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV515063Medicare Oscar/Certification