1528203049 NPI number — VIBRA HOSPITAL OF MAHONING VALLEY LLC

Table of content: (NPI 1528203049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528203049 NPI number — VIBRA HOSPITAL OF MAHONING VALLEY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIBRA HOSPITAL OF MAHONING VALLEY 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:
VIBRA HOSPITAL OF MAHONING VALLEY
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:
1528203049
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 EAST RIVER PARK PLACE E #460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93720-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-892-2500
Provider Business Mailing Address Fax Number:
559-892-2442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8049 SOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-6154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-726-5021
Provider Business Practice Location Address Fax Number:
330-726-5053
Provider Enumeration Date:
12/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FEGAN
Authorized Official First Name:
CLINT
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
SEC/TREAS
Authorized Official Telephone Number:
717-591-5700

Provider Taxonomy Codes

  • Taxonomy code: 282E00000X , with the licence number:  1428 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 282N00000X , with the licence number: 1428 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3140729 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1032312470001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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