1386195311 NPI number — ADVANCED LIFE SUPPORT CORP.

Table of content: (NPI 1386195311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386195311 NPI number — ADVANCED LIFE SUPPORT CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED LIFE SUPPORT CORP.
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:
1386195311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22403-6101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-207-9287
Provider Business Mailing Address Fax Number:
540-898-8138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11905 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22408-7326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-207-9284
Provider Business Practice Location Address Fax Number:
540-898-8138
Provider Enumeration Date:
10/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOHAMED
Authorized Official First Name:
MAWIA
Authorized Official Middle Name:
BAKRI
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-207-9284

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  166 , 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)