Provider Demographics
NPI:1669872057
Name:GREENBRIER COUNTY COMMITTEE ON AGING
Entity type:Organization
Organization Name:GREENBRIER COUNTY COMMITTEE ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-392-5138
Mailing Address - Street 1:284 GREENBRIER STREET
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:WV
Mailing Address - Zip Code:25984
Mailing Address - Country:US
Mailing Address - Phone:304-392-5138
Mailing Address - Fax:304-392-5969
Practice Address - Street 1:284 GREENBRIER STREET
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:WV
Practice Address - Zip Code:25984
Practice Address - Country:US
Practice Address - Phone:304-392-5138
Practice Address - Fax:304-392-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10362952251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0030600001Medicaid
WV0030600000Medicaid