Provider Demographics
NPI:1790865962
Name:MONONGALIA HOME CORPORATION
Entity Type:Organization
Organization Name:MONONGALIA HOME CORPORATION
Other - Org Name:SUNDALE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:304-599-0497
Mailing Address - Street 1:800 J D ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3474
Mailing Address - Country:US
Mailing Address - Phone:304-599-0497
Mailing Address - Fax:304-599-9083
Practice Address - Street 1:800 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3474
Practice Address - Country:US
Practice Address - Phone:304-599-0497
Practice Address - Fax:304-599-9083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1790865962Medicaid
WV0003876000Medicaid