1861480303 NPI number — TCC HOLDINGS CORPORATION

Table of content: (NPI 1861480303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861480303 NPI number — TCC HOLDINGS CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TCC HOLDINGS CORPORATION
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:
DIAMOND CARE CENTER
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:
1861480303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 N MAIN AVE
Provider Second Line Business Mailing Address:
PO BOX 300
Provider Business Mailing Address City Name:
BRIDGEWATER
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57319-2004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-729-2525
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEWATER
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57319-2004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-729-2525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GROFF
Authorized Official First Name:
HOWIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-888-2923

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  49737 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 10597 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9566750 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85115 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9566770 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9570430 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0160352 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9570580 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com