Provider Demographics
NPI:1063543585
Name:MOUNTAIN STATE HOME REHAB, INC.
Entity type:Organization
Organization Name:MOUNTAIN STATE HOME REHAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BANIAK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-707-3346
Mailing Address - Street 1:RR 5 BOX 521
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-9016
Mailing Address - Country:US
Mailing Address - Phone:301-707-3346
Mailing Address - Fax:304-726-4213
Practice Address - Street 1:RR 5 BOX 521
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-9016
Practice Address - Country:US
Practice Address - Phone:301-707-3346
Practice Address - Fax:304-726-4213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVMO9359121Medicare ID - Type Unspecified