Provider Demographics
NPI:1548253735
Name:MOUNTAIN HOSPICE INC
Entity type:Organization
Organization Name:MOUNTAIN HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:304-823-3922
Mailing Address - Street 1:1002 S CRIM AVE
Mailing Address - Street 2:
Mailing Address - City:BELINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26250-8203
Mailing Address - Country:US
Mailing Address - Phone:304-823-3922
Mailing Address - Fax:304-823-3926
Practice Address - Street 1:1002 S CRIM AVE
Practice Address - Street 2:
Practice Address - City:BELINGTON
Practice Address - State:WV
Practice Address - Zip Code:26250-8203
Practice Address - Country:US
Practice Address - Phone:304-823-3922
Practice Address - Fax:304-823-3926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22932194251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV511514OtherPTAN
WV0005168001Medicaid