Provider Demographics
NPI:1255332862
Name:ROSEWOOD MANOR
Entity type:Organization
Organization Name:ROSEWOOD MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-859-6496
Mailing Address - Street 1:PO BOX 6230
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0722
Mailing Address - Country:US
Mailing Address - Phone:304-242-7106
Mailing Address - Fax:304-242-7108
Practice Address - Street 1:214 4TH ST
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:OH
Practice Address - Zip Code:43971-1212
Practice Address - Country:US
Practice Address - Phone:740-859-6496
Practice Address - Fax:740-859-7120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0223010Medicaid
=========OtherMS BLUE CROSS BLUE SHIELD
OH0223010Medicaid