1861476442 NPI number — TRILOGY HEALTHCARE OF GREENVILLE, LLC

Table of content: (NPI 1861476442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861476442 NPI number — TRILOGY HEALTHCARE OF GREENVILLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRILOGY HEALTHCARE OF GREENVILLE, 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:
VILLAGE GREEN HEALTH CAMPUS
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:
1861476442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 221648
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40252-1648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-412-5847
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 KITCHEN AID WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45331-1394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-548-1993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PLEVYAK
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
SR. VICE PRESIDENT
Authorized Official Telephone Number:
502-213-1710

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2677 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0112671 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0060404 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0299725 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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