1497922843 NPI number — DINWIDDIE HEALTH CARE LLC

Table of content: (NPI 1497922843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497922843 NPI number — DINWIDDIE HEALTH CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
DINWIDDIE HEALTH CARE 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1497922843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5372 FALLOWATER LN
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-0907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-725-8910
Provider Business Mailing Address Fax Number:
540-725-8914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 DIAMOND DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23803-7495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-518-0780
Provider Business Practice Location Address Fax Number:
804-518-0787
Provider Enumeration Date:
05/14/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETRINE
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER MANAGER
Authorized Official Telephone Number:
540-725-8910

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1497922843 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 367817 . This is a "ANTHEM MEDIGAP NUMBER" identifier . This identifiers is of the category "OTHER".