Provider Demographics
NPI:1386687515
Name:SEVENTEENTH STREET ASSOCIATES LLC
Entity Type:Organization
Organization Name:SEVENTEENTH STREET ASSOCIATES LLC
Other - Org Name:HUNTINGTON HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP OPERATIONS FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-829-5100
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5161
Mailing Address - Country:US
Mailing Address - Phone:832-467-6000
Mailing Address - Fax:
Practice Address - Street 1:1720-17TH STREET
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-4235
Practice Address - Country:US
Practice Address - Phone:304-529-6031
Practice Address - Fax:304-525-3954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV8314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV150028WVAOtherPREVIOUS MEDICAID NUMBER
WV0002926000Medicaid
WV0002926000Medicaid