1740277359 NPI number — SOUTH BOSTON MANOR, LLC

Table of content: (NPI 1740277359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740277359 NPI number — SOUTH BOSTON MANOR, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BOSTON 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:
1740277359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 OAK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BOSTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24592-1634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-572-2925
Provider Business Mailing Address Fax Number:
434-572-8258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 OAK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BOSTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24592-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-572-2925
Provider Business Practice Location Address Fax Number:
434-572-8258
Provider Enumeration Date:
09/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SWAIN
Authorized Official First Name:
W.
Authorized Official Middle Name:
STEWART
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
843-902-4582

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2704 , 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: 010053650 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".