1508855115 NPI number — AUGUSTA RESOURCE CENTER ON AGING, INC.

Table of content: (NPI 1508855115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508855115 NPI number — AUGUSTA RESOURCE CENTER ON AGING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUGUSTA RESOURCE CENTER ON AGING, 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:
BRANDON WILDE
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:
1508855115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 OWENS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30809-3066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-868-3526
Provider Business Mailing Address Fax Number:
706-868-3525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4275 OWENS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30809-3066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-868-3526
Provider Business Practice Location Address Fax Number:
706-868-3525
Provider Enumeration Date:
10/17/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KISNER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
706-868-3527

Provider Taxonomy Codes

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

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