1275572646 NPI number — THE WATERS OF YORKTOWN, LLC

Table of content: (NPI 1275572646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275572646 NPI number — THE WATERS OF YORKTOWN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WATERS OF YORKTOWN, 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:
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:
1275572646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 FENCL LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSIDE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60162-2067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-449-1900
Provider Business Mailing Address Fax Number:
708-449-1500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 S. ANDREWS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORKTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47396-6812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-759-7740
Provider Business Practice Location Address Fax Number:
765-759-7131
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SORSCHER
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
708-449-1900

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  05-000143-1 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100283890C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000391196 . This is a "ANTHEM ST" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000381429 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000391199 . This is a "ANTHEM OT" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 5584850001 . This is a "DMERC REGION B SUPPLIER#" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000391198 . This is a "ANTHEM PT" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com