1164477089 NPI number — AVALON HOME, INC.

Table of content: (NPI 1164477089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164477089 NPI number — AVALON HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON HOME, INC.
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:
AVALON MANOR HEALTH CARE CENTER
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:
1164477089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14014 MARSH PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21742-1638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-733-8700
Provider Business Mailing Address Fax Number:
301-733-8700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14014 MARSH PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21742-1638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-733-8700
Provider Business Practice Location Address Fax Number:
301-733-8700
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEPHART
Authorized Official First Name:
MARLENE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
301-733-8700

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  21-001 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 278161 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02MM . This is a "CAREFIRST - PROV INQ#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5522258 . This is a "AETNA-HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: RT3 . This is a "CAREFIRST - BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: RT3 . This is a "CAREFIRST - IND/PPO" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com