Provider Demographics
NPI:1629101910
Name:MOUNTAINEER HOME HEALTH, LLC
Entity Type:Organization
Organization Name:MOUNTAINEER HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-720-0205
Mailing Address - Street 1:325 4TH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1266
Mailing Address - Country:US
Mailing Address - Phone:304-720-0205
Mailing Address - Fax:304-720-0262
Practice Address - Street 1:325 4TH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1266
Practice Address - Country:US
Practice Address - Phone:304-720-0205
Practice Address - Fax:304-720-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV90364251E00000X
WV2007-011,481251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0004241000Medicaid
WV0004241000Medicaid