1003890815 NPI number — REHABILITATION SERVICES OF DANVILLE

Table of content: MARY ANN KARLOK LMBT (NPI 1306276977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003890815 NPI number — REHABILITATION SERVICES OF DANVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REHABILITATION SERVICES OF DANVILLE
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:
1003890815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8833
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-0745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-772-8022
Provider Business Mailing Address Fax Number:
540-772-0294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
990 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-772-8022
Provider Business Practice Location Address Fax Number:
540-772-0294
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LUCAS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
540-772-8022

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  0105000005 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 193529 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4978269 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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