Organization
MOUNTAINEER HOME MEDICAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MICHELLE L JACKSON (BILLING MANAGER)
(304) 225-6290
Entity
Organization
Contact information
Practice address
5000 GREENBAG ROAD, SUITE F6, MORGANTOWN, WV 26501
(304) 225-6290
(304) 225-1115
Mailing address
5000 GREENBAG RD STE F6, MORGANTOWN, WV 26501-7123
(304) 225-6290
(304) 225-1115
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
770649
WV
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
CONTROLNUMBER72117
WV
332BC3200X
Customized Equipment (DME)
—
—
332BX2000X
Oxygen Equipment & Supplies (DME)
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001704877
BLUE CROSS BLUE SHIELD
WV
05
—
101294177 0001
—
PA
05
—
3810001835
—
WV
05
—
407251100
—
MD
01
—
DME315
HEALTH PLAN PROVIDER #
WV
Enumeration date
08/16/2005
Last updated
05/01/2026
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