Provider Demographics
NPI:1417963000
Name:WVDHHR JOHN MANCHIN SR HEALTH CARE CENTER
Entity Type:Organization
Organization Name:WVDHHR JOHN MANCHIN SR HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:304-363-2500
Mailing Address - Street 1:401 GUFFEY STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-363-2500
Mailing Address - Fax:304-363-0263
Practice Address - Street 1:401 GUFFEY STREET
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-363-2500
Practice Address - Fax:304-363-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C13880OtherMEDICARE RAILROAD
Y03944Medicare UPIN
7901101OPMedicare ID - Type Unspecified
5150752IPMedicare ID - Type Unspecified