Provider Demographics
NPI:1912992090
Name:ST. BARBARAS MEMORIAL NURSING HOME INC
Entity Type:Organization
Organization Name:ST. BARBARAS MEMORIAL NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SISTER MARY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-534-5220
Mailing Address - Street 1:PO BOX 9066
Mailing Address - Street 2:
Mailing Address - City:MONONGAH
Mailing Address - State:WV
Mailing Address - Zip Code:26555-9066
Mailing Address - Country:US
Mailing Address - Phone:304-534-5220
Mailing Address - Fax:304-534-4041
Practice Address - Street 1:OFF RT 19 - ST. BARBARAS ROAD
Practice Address - Street 2:
Practice Address - City:MONONGAH
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-534-5220
Practice Address - Fax:304-534-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003861000Medicaid
WV51-5012Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER