1578516795 NPI number — DHSC LLC

Table of content: XIOMARA REYES MARTINEZ AA (NPI 1609444744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578516795 NPI number — DHSC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DHSC 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:
6
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:
1578516795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10390
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46852-0390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-837-7200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3140 LINCOLN WAY E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASSILLON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44646-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-837-7200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLTSFORD
Authorized Official First Name:
LAURIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, BUSINESS OFFICE SUPPORT
Authorized Official Telephone Number:
615-465-7466

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  76-147811 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20021389 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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