1528434149 NPI number — THE JERICHO HOUSE

Table of content: (NPI 1528434149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528434149 NPI number — THE JERICHO HOUSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE JERICHO HOUSE
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:
1528434149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 HIGHWAY 255 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUTEE NACOOCHEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30571-2622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-878-0015
Provider Business Mailing Address Fax Number:
706-878-0037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6757 DUNCAN BRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30528-5170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-878-0015
Provider Business Practice Location Address Fax Number:
706-878-0037
Provider Enumeration Date:
08/18/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCKENNA
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
706-878-0015

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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