1063545176 NPI number — SOUTHAMPTON BEHAVIORAL HEALTHCARE, LLC

Table of content: (NPI 1063545176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063545176 NPI number — SOUTHAMPTON BEHAVIORAL HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHAMPTON BEHAVIORAL HEALTHCARE, 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:
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:
1063545176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 633
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23851-0633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-569-0007
Provider Business Mailing Address Fax Number:
757-569-0011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 FAIRVIEW DR
Provider Second Line Business Practice Location Address:
BLDG. 2, SUITE 200-B
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23851-1238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-569-0007
Provider Business Practice Location Address Fax Number:
757-569-0011
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REED,
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
757-569-0007

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  0701003254 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X , with the licence number: 3450 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2084P0800X , with the licence number: 0101050005 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 548467 . This is a "VALUEOPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 069022 . This is a "VALUEOPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 186340 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: O86305M . This is a "SBHS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 186337 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 368995 . This is a "MHN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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