1063789808 NPI number — JAMES RICK MCCALLISTER LICENSED CLINICAL AD

Table of content: JAMES RICK MCCALLISTER LICENSED CLINICAL AD (NPI 1063789808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063789808 NPI number — JAMES RICK MCCALLISTER LICENSED CLINICAL AD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCALLISTER
Provider First Name:
JAMES
Provider Middle Name:
RICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICENSED CLINICAL AD
Provider Gender Code:
M

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:
1063789808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 W. MILLS ST., PO BOX 130
Provider Second Line Business Mailing Address:
POLK WELLNESS CENTER
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
28722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-894-2222
Provider Business Mailing Address Fax Number:
828-894-2229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 W. MILLS ST.
Provider Second Line Business Practice Location Address:
POLK WELLNESS CENTER
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
28722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-894-2222
Provider Business Practice Location Address Fax Number:
828-894-2229
Provider Enumeration Date:
11/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  1746 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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