1417039116 NPI number — DEACONESS VNA PLUS, LLC

Table of content: (NPI 1417039116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417039116 NPI number — DEACONESS VNA PLUS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEACONESS VNA PLUS, 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:
1417039116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 US HIGHWAY 45 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELDORADO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62930-3765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-273-9305
Provider Business Mailing Address Fax Number:
618-273-2469

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 US HIGHWAY 45 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELDORADO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62930-3765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-273-9305
Provider Business Practice Location Address Fax Number:
618-273-2469
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HORTON
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
812-425-3561

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1011757 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350868076001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 323485 . This is a "BLUE CROSS PRINCETON" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 323484 . This is a "BLUE CROSS TELL CITY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: V255P9657A501475 . This is a "VA PROVIDER # MARIAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 201266990A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34-340042 . This is a "KENTUCKY PROVIDER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 186268 . This is a "BLUE CROSS EVANSVILLE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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