1407937709 NPI number — ANDALUSIA MANOR LLC

Table of content: (NPI 1407937709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407937709 NPI number — ANDALUSIA MANOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDALUSIA MANOR 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:
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:
1407937709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 MOORE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDALUSIA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-222-4544
Provider Business Mailing Address Fax Number:
334-222-4737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
670 MOORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDALUSIA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-222-4544
Provider Business Practice Location Address Fax Number:
334-222-4737
Provider Enumeration Date:
10/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SASSER
Authorized Official First Name:
SAL-LEE
Authorized Official Middle Name:
SHA-REE
Authorized Official Title or Position:
VICE-PRESIDENT
Authorized Official Telephone Number:
334-222-4544

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4757890S , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".