1154574630 NPI number — GERIATRIC SPECIALTY CARE LLC

Table of content: (NPI 1154574630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154574630 NPI number — GERIATRIC SPECIALTY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERIATRIC SPECIALTY CARE LLC
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:
ALICIA WOLF NP
Provider Other Organization Name Type Code:
3
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:
1154574630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 670486
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44067-0486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 3RD ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBERTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44203-4208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-666-6457
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WOLF
Authorized Official First Name:
ALICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
440-666-6457

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  COA08023-NP , 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: 2881725 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com