Provider Demographics
NPI:1790224400
Name:HOSPICE OF SOUTHERN WV DBA PALLIATIVE CARE OF SOUTHERN WEST VIRGINIA
Entity Type:Organization
Organization Name:HOSPICE OF SOUTHERN WV DBA PALLIATIVE CARE OF SOUTHERN WEST VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JANETT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-252-6404
Mailing Address - Street 1:PO BOX 1472
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-1472
Mailing Address - Country:US
Mailing Address - Phone:304-255-6404
Mailing Address - Fax:304-255-6494
Practice Address - Street 1:456 CRANBERRY DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-8560
Practice Address - Country:US
Practice Address - Phone:304-255-6404
Practice Address - Fax:304-255-6494
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPICE OF SOUTHERN WV
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-14
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV6363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVG210Medicare PIN