1083268189 NPI number — MISSION CREEK TRANSITIONAL CARE PLLC

Table of content: (NPI 1083268189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083268189 NPI number — MISSION CREEK TRANSITIONAL CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION CREEK TRANSITIONAL CARE PLLC
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:
1083268189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5261 CARROLLTON PIKE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODLAWN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24381-3034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-238-0911
Provider Business Mailing Address Fax Number:
276-238-0912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 MARSHALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55803-1981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-340-8674
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-340-8674

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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