1851465629 NPI number — COMMUNITY MEMORIAL HEALTHCENTER

Table of content: (NPI 1851465629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851465629 NPI number — COMMUNITY MEMORIAL HEALTHCENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY MEMORIAL HEALTHCENTER
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:
COMMUNITY MEMORIAL DIALYSIS
Provider Other Organization Name Type Code:
5
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:
1851465629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH HILL
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23970-0090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 BUENA VISTA CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH HILL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23970-1431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-774-2400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TATUM
Authorized Official First Name:
RONNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF FINANCE, CFO
Authorized Official Telephone Number:
434-774-2400

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004900987 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000055 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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