Provider Demographics
NPI:1275232043
Name:MOUNTAINEER LIFE ENRICHMENT CENTER, LLC
Entity Type:Organization
Organization Name:MOUNTAINEER LIFE ENRICHMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SEARS
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:304-373-4678
Mailing Address - Street 1:1522 BUNNER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5079
Mailing Address - Country:US
Mailing Address - Phone:304-373-4678
Mailing Address - Fax:
Practice Address - Street 1:1522 BUNNER RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5079
Practice Address - Country:US
Practice Address - Phone:304-373-4678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherSELF PAY