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Contact Information

1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC
1543 COUNTRY CLUB RD
FAIRMONT, WV26554-1306
 Phone: 304-363-2273
 Fax:
 Website:
 

Specialty

Taxonomy Code Specialty Code Provider Type

Skilled Nursing Facility

314000000X A1[8] Skilled Nursing Facility
Indicates primary specialty

NPI Profile & details for 1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC

NPI Number 1396981064
LBN Legal business name 1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC
Authorized official MICHAEL BERG - (SECRETARY)
Entity Organization
Organization subpart 1 No
Enumeration date 12/30/2008
Last updated 07/09/2025 - About 11 months ago
Identifiers
WV License # 59
WV Medicaid 3810013993
1 Some organization health care providers are made up of components that furnish different types of health care or have separate physical locations where health care is furnished. These components and physical locations are not themselves legal entities, but are part of the organization health care provider (which is a legal entity). A covered organization provider may decide that its subparts (if it has any) should have their own NPI numbers. If a subpart conducts any HIPAA standard transactions on its own (e.g., separately from its parent), it must obtain its own NPI number.

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