1144375767 NPI number — OCTOBER ROAD INC.

Table of content: (NPI 1144375767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144375767 NPI number — OCTOBER ROAD INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCTOBER ROAD 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:
1144375767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 TUNNEL RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
ASHEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28805-1869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-350-1000
Provider Business Mailing Address Fax Number:
828-350-1300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 TUNNEL RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28805-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-350-1000
Provider Business Practice Location Address Fax Number:
828-350-1300
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKS
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
814-940-0407

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  MLH-011-272 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MHL-011-272 . This is a "NC DHSR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5905845 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6006159 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8703016 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3410004 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8305312 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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