1144342338 NPI number — GERIATRIC FOOT CARE OF W VIR

Table of content: (NPI 1144342338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144342338 NPI number — GERIATRIC FOOT CARE OF W VIR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERIATRIC FOOT CARE OF W VIR
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:
1144342338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9016 TAYLORSVILLE RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40299-1750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-724-0900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 FAIRMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-3494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-724-0900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FOLICKMAN
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
502-724-0900

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  00142 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0007469000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: C31093 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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