1194195834 NPI number — ADVANCED PRACTICE ADULT-GERONTOLOGY

Table of content: (NPI 1194195834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194195834 NPI number — ADVANCED PRACTICE ADULT-GERONTOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PRACTICE ADULT-GERONTOLOGY
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:
1194195834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 PINEY VIEW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUTH OF WILSON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24363-3694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-768-9058
Provider Business Mailing Address Fax Number:
276-783-2879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5140 HATCHER RD
Provider Second Line Business Practice Location Address:
FAIRVIEW HOME
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24084-4802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-431-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SPENCER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
276-768-9058

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  0017142291 , 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)





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