1194871970 NPI number — GRANVILLE-VANCE DISTRICT HEALTH DEPARTMENT

Table of content: (NPI 1194871970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194871970 NPI number — GRANVILLE-VANCE DISTRICT HEALTH DEPARTMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANVILLE-VANCE DISTRICT HEALTH DEPARTMENT
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:
MASS IMMUNIZATON SERVICES
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:
1194871970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 HUNT ST
Provider Second Line Business Mailing Address:
PO BOX 367
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27565-3414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-693-2141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 HUNT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27565-3414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-693-2141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUTHRIE
Authorized Official First Name:
SHAUNA
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
919-693-2141

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0721N . This is a "BCBS GRANVILLE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3404416 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3404391 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3404339 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0721P . This is a "VANCE BCBS" identifier . This identifiers is of the category "OTHER".




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