Provider Demographics
NPI:1568847606
Name:MARTINSBURG CENTER LLC
Entity Type:Organization
Organization Name:MARTINSBURG CENTER LLC
Other - Org Name:CLARY GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-343-1950
Mailing Address - Street 1:7500 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2935
Mailing Address - Country:US
Mailing Address - Phone:304-343-1950
Mailing Address - Fax:304-343-1947
Practice Address - Street 1:209 CLOVER ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-3803
Practice Address - Country:US
Practice Address - Phone:304-263-8921
Practice Address - Fax:304-263-2548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV515039Medicare Oscar/Certification