1063592608 NPI number — ESSENTIAL LIFE THERAPIES INC

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 1063592608 NPI number — ESSENTIAL LIFE THERAPIES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESSENTIAL LIFE THERAPIES 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:
1063592608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4127
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:
24015-0127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-981-9394
Provider Business Mailing Address Fax Number:
540-344-7154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5507 DOWNING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-8704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-989-0315
Provider Business Practice Location Address Fax Number:
540-774-1292
Provider Enumeration Date:
10/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLAXTON
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
540-989-0315

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008925721 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 215418 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".