1922087352 NPI number — VANGUARD OF RIPLEY, LLC

Table of content: (NPI 1922087352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922087352 NPI number — VANGUARD OF RIPLEY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANGUARD OF RIPLEY, LLC
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:
REST HAVEN HEALTH AND REHABILITATION
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:
1922087352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9020 OVERLOOK BLVD STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-250-7100
Provider Business Mailing Address Fax Number:
615-250-7101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 CUNNINGHAM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIPLEY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-837-3062
Provider Business Practice Location Address Fax Number:
662-837-1395
Provider Enumeration Date:
01/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ORAND
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
615-250-7100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  337 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00230095 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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