1194105247 NPI number — NEW RIVER MEDICCAL MASSAGE

Table of content: (NPI 1194105247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194105247 NPI number — NEW RIVER MEDICCAL MASSAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW RIVER MEDICCAL MASSAGE
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:
1194105247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
319 WEST MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RADFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-633-3828
Provider Business Mailing Address Fax Number:
540-633-3829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RADFORD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24141-1586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-633-3828
Provider Business Practice Location Address Fax Number:
540-633-3829
Provider Enumeration Date:
06/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ERNEST
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
540-633-3828

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0019001695 , 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: 225700000X . This is a "MASSAGE THERAPY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com