Active NPI
1543 Country Club Road Manor Operations LLC
Doing business as Wishing Well Assisted Living Community at Fairmont Campus
- Assisted Living Facility
- Fairmont, WV
National Provider Identifier
1942446745
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Assisted Living Facility
- License
- 506062
- Legal business name
- 1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC
- Doing business as
- Wishing Well Assisted Living Community at Fairmont Campus
- Practice address
- 1543 Country Club Rd
Fairmont, WV 26554-1306 - Phone
- (304) 363-2273
- NPI assigned
- Dec 29, 2008
- Last updated
- Jul 9, 2025
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Michael T Berg
- Title
- Secretary
- Phone
- (610) 444-6350
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Assisted Living Facility | 310400000X | 506062 | WV | Primary |
Addresses
Primary practice location
1543 Country Club Rd
Fairmont, WV 26554-1306
Mailing address
101 E State St
Kennett Square, PA 19348-3109
Phone (610) 925-4436
Other names 1
- Wishing Well Assisted Living Community at Fairmont Campus
National Provider Directory
National Provider Directory- Tax ID family
- 1543 Country Club Road Manor Operations LLC
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
dba Pierpont Center at Fairmont Campus
- Skilled Nursing Facility
- Fairmont, WV
- NPI 1396981064
Locations
1543 Country Club Rd
Fairmont, WV 26554
Phone (304) 363-2273
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1230508800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1752019200000",
"number": "1942446745",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "101 E STATE ST",
"city": "KENNETT SQUARE",
"state": "PA",
"postal_code": "193483109",
"telephone_number": "610-925-4436",
"fax_number": "610-347-4099"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1543 COUNTRY CLUB RD",
"city": "FAIRMONT",
"state": "WV",
"postal_code": "265541306",
"telephone_number": "304-363-2273"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC",
"organizational_subpart": "NO",
"enumeration_date": "2008-12-29",
"last_updated": "2025-07-09",
"certification_date": "2025-07-09",
"status": "A",
"authorized_official_last_name": "BERG",
"authorized_official_first_name": "MICHAEL",
"authorized_official_middle_name": "T",
"authorized_official_title_or_position": "SECRETARY",
"authorized_official_telephone_number": "610-444-6350"
},
"taxonomies": [
{
"code": "310400000X",
"taxonomy_group": "",
"desc": "Assisted Living Facility",
"state": "WV",
"license": "506062",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "Wishing Well Assisted Living Community at Fairmont Campus",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Fairmont, WV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.