Provider Demographics
NPI:1205344355
Name:JACOB'S LADDER AT BROOKSIDE FARM, LLC
Entity type:Organization
Organization Name:JACOB'S LADDER AT BROOKSIDE FARM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-290-0000
Mailing Address - Street 1:515 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-6607
Mailing Address - Country:US
Mailing Address - Phone:304-290-0000
Mailing Address - Fax:304-290-0000
Practice Address - Street 1:25208 GEORGE WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:WV
Practice Address - Zip Code:26705-8036
Practice Address - Country:US
Practice Address - Phone:304-239-1214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder