Provider Demographics
NPI:1871659730
Name:FAYETTE NURSING & REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:FAYETTE NURSING & REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-344-1623
Mailing Address - Street 1:100 HRESAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1333
Mailing Address - Country:US
Mailing Address - Phone:304-574-0770
Mailing Address - Fax:304-574-1434
Practice Address - Street 1:100 HRESAN BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1333
Practice Address - Country:US
Practice Address - Phone:304-574-0770
Practice Address - Fax:304-574-1434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV48314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003077000Medicaid
WV515153Medicare ID - Type UnspecifiedMEDICARE NUMBER