Provider Demographics
NPI:1831293042
Name:CENTRA HEALTH INC
Entity Type:Organization
Organization Name:CENTRA HEALTH INC
Other - Org Name:FAIRMONT CROSSING REHABILITATION & HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SRVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-4708
Mailing Address - Street 1:PO BOX 2496
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24505
Mailing Address - Country:US
Mailing Address - Phone:434-947-3777
Mailing Address - Fax:434-947-4763
Practice Address - Street 1:173 BROCKMAN PK DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:VA
Practice Address - Zip Code:24521
Practice Address - Country:US
Practice Address - Phone:434-947-3777
Practice Address - Fax:434-947-4763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2519313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000344OtherANTHEM
VA004967232Medicaid
VA000344OtherANTHEM