1396963591 NPI number — ADVANCED CHIROPRACTIC PC

Table of content: (NPI 1396963591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396963591 NPI number — ADVANCED CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED CHIROPRACTIC PC
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:
1396963591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 RIVERSIDE DR
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24541-5641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-822-2222
Provider Business Mailing Address Fax Number:
434-822-2101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 RIVERSIDE DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24541-5641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-822-2222
Provider Business Practice Location Address Fax Number:
434-822-2101
Provider Enumeration Date:
04/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLACKMORE
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER OPERATOR
Authorized Official Telephone Number:
434-822-2222

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  0104001140 , 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: 134162 . This is a "GATEWAY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 216628 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 288977 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 350053242 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".