1265450753 NPI number — TRIVIUM LLC

Table of content: (NPI 1265450753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265450753 NPI number — TRIVIUM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIVIUM LLC
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:
CROSSROADS COUNSELING 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:
1265450753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 S. RIVER ST
Provider Second Line Business Mailing Address:
SUITE 254
Provider Business Mailing Address City Name:
JANESVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53548-3863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-755-5260
Provider Business Mailing Address Fax Number:
608-755-5267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 S. RIVER ST.
Provider Second Line Business Practice Location Address:
SUITE 254
Provider Business Practice Location Address City Name:
JANESVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53548-3863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-755-5260
Provider Business Practice Location Address Fax Number:
608-755-5267
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
608-755-5260

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: 1265 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0855X , with the licence number: 1265 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: 2868 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 42105900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com