Provider Demographics
NPI:1871686717
Name:HOSPICE OF SOUTHERN WEST VIRGINIA, INC
Entity Type:Organization
Organization Name:HOSPICE OF SOUTHERN WEST VIRGINIA, INC
Other - Org Name:PALLIATIVE CARE OF SOUTHERN WEST VIRGINIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANETT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-255-6404
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV6251G00000X
315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005593000Medicaid
WV0005593000Medicaid