1992728208 NPI number — LIFE GUARD INC

Table of content: DUSTIN CARR (NPI 1164281184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992728208 NPI number — LIFE GUARD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE GUARD INC
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:
LIFE GUARD MEDICAL SUPPLY
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:
1992728208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776
Provider Second Line Business Mailing Address:
401 RIVERVIEW DR
Provider Business Mailing Address City Name:
BELMONT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-665-2346
Provider Business Mailing Address Fax Number:
304-665-9402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 RIVERVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
604-665-2346
Provider Business Practice Location Address Fax Number:
304-665-9402
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
JOESPH
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-665-2346

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0147202000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0232573 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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