1740270297 NPI number — LAUREL MEADOWS LIFE CARE L C

Table of content: (NPI 1740270297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740270297 NPI number — LAUREL MEADOWS LIFE CARE L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUREL MEADOWS LIFE CARE L C
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:
HERITAGE HALL LAUREL MEADOWS
Provider Other Organization Name Type Code:
5
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:
1740270297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3131 ELECTRIC RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-6427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-774-4263
Provider Business Mailing Address Fax Number:
540-774-0780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16600 DANVILLE PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUREL FORK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24352-3804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-398-2117
Provider Business Practice Location Address Fax Number:
276-398-3122
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAINES
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CCO AND GENERAL COUNSEL
Authorized Official Telephone Number:
540-774-4263

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2578 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 227198 . This is a "ANTHEM BCBS PPO ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 608690100 . This is a "FEDERAL BLACK LUNG ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C495323 . This is a "UNITED AMERICAN INS CO ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4953231 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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