1013386929 NPI number — JUSTIN GROCE APRN

Table of content: JUSTIN GROCE APRN (NPI 1013386929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013386929 NPI number — JUSTIN GROCE APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROCE
Provider First Name:
JUSTIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

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:
1013386929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 WINWOOD DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37087-1340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-444-4126
Provider Business Mailing Address Fax Number:
855-785-2890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 WINWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37087-1340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-444-4126
Provider Business Practice Location Address Fax Number:
855-785-2890
Provider Enumeration Date:
09/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  20598 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6060213 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P01697499 . This is a "R/R MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: Q021233 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3306523 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 620842749 . This is a "HUMANA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com