1962642520 NPI number — VILLAGE OF MANCHESTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962642520 NPI number — VILLAGE OF MANCHESTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE OF MANCHESTER
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:
6
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:
1962642520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48193-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-224-4744
Provider Business Mailing Address Fax Number:
734-479-6319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 E. 5TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-549-3358
Provider Business Practice Location Address Fax Number:
937-549-2502
Provider Enumeration Date:
02/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
STRIBLEN KIRK
Authorized Official First Name:
MARLA
Authorized Official Middle Name:
CHANE
Authorized Official Title or Position:
CAPTAIN
Authorized Official Telephone Number:
513-503-9710

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000622255 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2961595 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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