Provider Demographics
NPI:1154596757
Name:HOME BASE INC MDGRP
Entity type:Organization
Organization Name:HOME BASE INC MDGRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:C
Authorized Official - Last Name:CATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-472-8707
Mailing Address - Street 1:PO BOX 2024
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-7024
Mailing Address - Country:US
Mailing Address - Phone:304-472-8707
Mailing Address - Fax:304-472-8978
Practice Address - Street 1:5 1/2 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2235
Practice Address - Country:US
Practice Address - Phone:304-472-8707
Practice Address - Fax:304-472-8978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV135251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007185Medicaid