1649396508 NPI number — DEFELICECARE, INC.

Table of content: (NPI 1649396508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649396508 NPI number — DEFELICECARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEFELICECARE, 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:
1649396508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 SIXTEENTH ST
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26003-0618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-232-4210
Provider Business Mailing Address Fax Number:
304-232-4213

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 ROCKDALE RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FOLLANSBEE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26037-1658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-723-0280
Provider Business Practice Location Address Fax Number:
304-723-0248
Provider Enumeration Date:
03/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEFELICE
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
304-232-4210

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  054968 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: 054968 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1007375850010 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001705530 . This is a "BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0147477000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".