1245244367 NPI number — CHANGE, INCORPORATED

Table of content: DR. DANIEL WINSTON IVES M.D. (NPI 1750315412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245244367 NPI number — CHANGE, INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANGE, INCORPORATED
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:
FAMILY MEDICAL CARE COMMUNITY HEALTH 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:
1245244367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3136 WEST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEIRTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26062-4635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-797-7733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3136 WEST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEIRTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26062-4635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-797-7733
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAVEAUX
Authorized Official First Name:
JUDY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
304-797-7733

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2161000 . This is a "CHANGE DBA FAMILY MEDICAL CARE CHC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2733993 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810007536 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 361015 . This is a "200 LURAY DRIVE WINTERSVILLE OH MEDICARE SITE #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2160961 . This is a "CHANGE OH LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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