Provider Demographics
NPI:1679964738
Name:MOUNTAINHEART COMMUNITY SERVICES, INC.
Entity type:Organization
Organization Name:MOUNTAINHEART COMMUNITY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-682-8271
Mailing Address - Street 1:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-1509
Mailing Address - Country:US
Mailing Address - Phone:304-682-8271
Mailing Address - Fax:304-682-8274
Practice Address - Street 1:33 MOUNTAINHEART LANE
Practice Address - Street 2:
Practice Address - City:MATHENY
Practice Address - State:WV
Practice Address - Zip Code:24860
Practice Address - Country:US
Practice Address - Phone:304-682-8271
Practice Address - Fax:304-682-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1035-1099252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810025021Medicaid