1104928514 NPI number — WYTHE COUNTY COMMUNITY HOSPITAL LLC

Table of content: (NPI 1104928514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104928514 NPI number — WYTHE COUNTY COMMUNITY HOSPITAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYTHE COUNTY COMMUNITY HOSPITAL 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:
HOSPICE OF SOUTHWEST VIRGINIA
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:
1104928514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
615-920-8913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 W RIDGE RD
Provider Second Line Business Practice Location Address:
HOSPICE OF SOUTHWEST VIRGINIA
Provider Business Practice Location Address City Name:
WYTHEVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-228-1710
Provider Business Practice Location Address Fax Number:
276-228-1719
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GIOVANETTI
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-920-7000

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  HSP06121 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004910141 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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