1295870194 NPI number — EMBRENCHE LLC

Table of content: (NPI 1295870194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295870194 NPI number — EMBRENCHE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMBRENCHE 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:
EMBRENCHE
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:
1295870194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 S MARSHALL ST STE 262
Provider Second Line Business Mailing Address:
1001 S MARSHALL STREET SUITE 262
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27101-5852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-722-8055
Provider Business Mailing Address Fax Number:
336-722-4161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 S MARSHALL ST STE 262
Provider Second Line Business Practice Location Address:
1001 S MARSHALL STREET SUITE 262
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27101-5852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-722-8055
Provider Business Practice Location Address Fax Number:
336-722-4161
Provider Enumeration Date:
02/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HICKMAN
Authorized Official First Name:
MARTY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
336-624-9618

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 6005992 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".