Provider Demographics
NPI:1063906303
Name:MOUNDSVILLE CENTER LLC
Entity type:Organization
Organization Name:MOUNDSVILLE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-343-1950
Mailing Address - Street 1:700 CHAPPELL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2704
Mailing Address - Country:US
Mailing Address - Phone:304-343-1950
Mailing Address - Fax:304-343-1947
Practice Address - Street 1:2200 FLORAL ST
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-1293
Practice Address - Country:US
Practice Address - Phone:304-843-1035
Practice Address - Fax:304-843-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility