1629283536 NPI number — NORTHERN GREENBRIER HEALTH CLINIC, INC

Table of content: (NPI 1629283536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629283536 NPI number — NORTHERN GREENBRIER HEALTH CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN GREENBRIER HEALTH CLINIC, 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:
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:
1629283536
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24991-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-645-7872
Provider Business Mailing Address Fax Number:
304-645-7873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RT 219 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24946-0470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-653-4209
Provider Business Practice Location Address Fax Number:
304-653-4233
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CURRY
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
304-645-7872

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: N051119281 . This is a "PALMETTO GBA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810009778 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 511928 . This is a "FQHC MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 731098 . This is a "CARELINK" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 51D0685085 . This is a "CLIA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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