Provider Demographics
NPI:1407164254
Name:RSCR WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:RSCR WEST VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-7425
Mailing Address - Street 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7101
Mailing Address - Country:US
Mailing Address - Phone:800-866-0860
Mailing Address - Fax:
Practice Address - Street 1:176 SANDFIELD ROAD
Practice Address - Street 2:
Practice Address - City:WARDENSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26851
Practice Address - Country:US
Practice Address - Phone:304-260-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC054503500Medicaid