1508266826 NPI number — BLACK RIVER HEALTH SERVICES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508266826 NPI number — BLACK RIVER HEALTH SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK RIVER HEALTH SERVICES 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:
BLACK RIVER FAMILY PRACTICE
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:
1508266826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5626 OBERLIN DR
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92121-1705
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:
301 S CAMPBELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURGAW
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28425-5011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-259-5721
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HEINE
Authorized Official First Name:
KENNY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
858-964-1506

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  2006-01488 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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