1578958146 NPI number — K VA T FOOD STORES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578958146 NPI number — K VA T FOOD STORES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
K VA T FOOD STORES INC.
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:
1578958146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/25/2016
NPI Reactivation Date:
02/11/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABINGDON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24212-1158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-623-5100
Provider Business Mailing Address Fax Number:
276-623-5440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1317 VIRGINIA AVE
Provider Second Line Business Practice Location Address:
HWY 421
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-5158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-623-5100
Provider Business Practice Location Address Fax Number:
276-623-5440
Provider Enumeration Date:
04/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CHAIRMAN PRESIDENT CEO
Authorized Official Telephone Number:
276-623-5100

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q021826 . This is a "MEDICAID DME" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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