1114197340 NPI number — CHAGRIN VALLEY PSYCHIATRIC ASSOCIATES INC

Table of content: NANCY VASQUEZ PA-C (NPI 1407541956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114197340 NPI number — CHAGRIN VALLEY PSYCHIATRIC ASSOCIATES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAGRIN VALLEY PSYCHIATRIC ASSOCIATES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114197340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7500 THATCHUM LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENTOR
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44060-6814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-227-3691
Provider Business Mailing Address Fax Number:
863-438-6126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 THATCHUM LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENTOR
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44060-6814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-227-3691
Provider Business Practice Location Address Fax Number:
863-438-6126
Provider Enumeration Date:
03/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GATES
Authorized Official First Name:
TODD
Authorized Official Middle Name:
JACOB
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
440-227-3691

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  34004091 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CH92497315 . This is a "MEDICARE GROUP PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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