Provider Demographics
NPI:1700050861
Name:MULBERRY STREET MANAGEMENT SERVICES, INC
Entity Type:Organization
Organization Name:MULBERRY STREET MANAGEMENT SERVICES, INC
Other - Org Name:COORDINATING COUNCIL FOR INDEPENDENT LIVING/WEST VIRGINIA SELECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PLEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-291-9066
Mailing Address - Street 1:1097 GREENBAG RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1532
Mailing Address - Country:US
Mailing Address - Phone:304-291-9066
Mailing Address - Fax:304-291-2119
Practice Address - Street 1:1097 GREENBAG RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1532
Practice Address - Country:US
Practice Address - Phone:304-291-9066
Practice Address - Fax:304-291-2119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherPRIVATE PAY