1730485376 NPI number — FRANK EDWARD IVAN III P.T.

Table of content: RILEY ALEXANDER (NPI 1235005760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730485376 NPI number — FRANK EDWARD IVAN III P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVAN
Provider First Name:
FRANK
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
P.T.
Provider Gender Code:
M

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:
1730485376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
296 BIG TIMBER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPON BRIDGE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26711-8943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-860-5366
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2650 S PLEASANT VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22601-6518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-228-1941
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  004477 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2305206758 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K949 - 0077 . This is a "CAREFIRST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2307001197 . This is a "DIRECT ACCESS CERTIFICATION" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".