1932288107 NPI number — 7TH AVE CLINIC

Table of content: (NPI 1932288107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932288107 NPI number — 7TH AVE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
7TH AVE CLINIC
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:
1932288107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 74 BOX 284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25951-9121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
394-673-1913
Provider Business Mailing Address Fax Number:
304-466-1676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
623 TEMPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HINTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-673-1913
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANDERS
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-673-1913

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  889 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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