1982994307 NPI number — STATEWIDE HEALTHCARE INC.

Table of content: DR. DAN THANH LINH NGUYEN DMD (NPI 1992452759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982994307 NPI number — STATEWIDE HEALTHCARE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATEWIDE HEALTHCARE 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:
1982994307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 OGLETHORPE PROFESSIONAL CT
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-3600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-231-8958
Provider Business Mailing Address Fax Number:
912-234-7701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 OGLETHORPE PROFESSIONAL CT
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31406-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-231-8958
Provider Business Practice Location Address Fax Number:
912-234-7701
Provider Enumeration Date:
04/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
912-231-8958

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 123456789 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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