1376510644 NPI number — MEMORIAL FAMILY CARE INC

Table of content: (NPI 1770681645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376510644 NPI number — MEMORIAL FAMILY CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL FAMILY CARE INC
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:
1376510644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10399
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24543-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-792-3730
Provider Business Mailing Address Fax Number:
434-792-6048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 RISON ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24541-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-792-3730
Provider Business Practice Location Address Fax Number:
434-792-6048
Provider Enumeration Date:
03/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEAL
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
434-792-3730

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101053147 , 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: 89063VU . This is a "EDS NC MEDICAID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 258015 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: CL9316 . This is a "PALMETTO GBA MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 005619505 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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