1790796639 NPI number — PENINSULA BIOMEDICAL INC

Table of content: (NPI 1790796639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790796639 NPI number — PENINSULA BIOMEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA BIOMEDICAL 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:
1790796639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 66149
Provider Second Line Business Mailing Address:
108 WHISPERING PINES DR SUITE 115
Provider Business Mailing Address City Name:
SCOTTS VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-430-9066
Provider Business Mailing Address Fax Number:
831-430-9068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500-01 WAIT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-556-8934
Provider Business Practice Location Address Fax Number:
919-556-0693
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
TONY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
831-430-9066

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  00508 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X , with the licence number: 00508 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , with the licence number: 00508 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010107199 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0428V . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 9001254300 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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