1265463566 NPI number — SNOWSHOE LTC GROUP, LLC

Table of content: (NPI 1265463566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265463566 NPI number — SNOWSHOE LTC GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNOWSHOE LTC GROUP, 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:
WAYLAND NURSING AND REHABILITATION 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:
1265463566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 719
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEYSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23947-0719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-736-8406
Provider Business Mailing Address Fax Number:
434-736-9334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 LUNENBURG HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEYSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-736-8406
Provider Business Practice Location Address Fax Number:
434-736-9334
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOICE
Authorized Official First Name:
GALE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
252-523-9094

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  NH2522 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: NH2522 , 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: 227057 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4952260 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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