1710443833 NPI number — SIRACH HEALTH PROFESSIONAL LIMITED LIABILITY COMPANY

Table of content: (NPI 1710443833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710443833 NPI number — SIRACH HEALTH PROFESSIONAL LIMITED LIABILITY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIRACH HEALTH PROFESSIONAL LIMITED LIABILITY COMPANY
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:
SIRACH HEALTH LLC
Provider Other Organization Name Type Code:
3
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:
1710443833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 847
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORDOVA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38088-0847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-821-0338
Provider Business Mailing Address Fax Number:
844-325-0416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4070 US HIGHWAY 17 BYPASS SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-306-8363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ROQUE
Authorized Official First Name:
JOEY
Authorized Official Middle Name:
EDWARD MALONJARO
Authorized Official Title or Position:
CEO, SOLE MEMBER
Authorized Official Telephone Number:
865-306-8363

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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