1013761725 NPI number — BANNER OF SUPPORT LLC

Table of content: (NPI 1013761725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013761725 NPI number — BANNER OF SUPPORT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANNER OF SUPPORT 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:
BANNER OF SUPPORT
Provider Other Organization Name Type Code:
5
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:
1013761725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5435
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23605-0435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-251-0655
Provider Business Mailing Address Fax Number:
757-325-6685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3411 SUNNYSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23666-3706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-251-0655
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JEFFREY
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
757-251-0655

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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