1457378804 NPI number — ALLIANCE FAMILY PRACTICE, PC

Table of content: (NPI 1457378804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457378804 NPI number — ALLIANCE FAMILY PRACTICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIANCE FAMILY PRACTICE, 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:
1457378804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 S CRATER RD
Provider Second Line Business Mailing Address:
SUITE 3A
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23805-9276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-733-3438
Provider Business Mailing Address Fax Number:
804-733-7424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 S CRATER RD
Provider Second Line Business Practice Location Address:
SUITE 3A
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23805-9276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-733-3438
Provider Business Practice Location Address Fax Number:
804-733-7424
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOOKER
Authorized Official First Name:
ALFREDA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
804-323-5575

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  0024131004 , 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: 0024131004 . This is a "STATE ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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