1083675474 NPI number — VIRGINIA DEPARTMENT OF HEALTH

Table of content: (NPI 1083675474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083675474 NPI number — VIRGINIA DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRGINIA DEPARTMENT OF HEALTH
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:
1083675474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 768
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTWOOD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24228-0768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-926-4979
Provider Business Mailing Address Fax Number:
276-926-4426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
334 BRUSH CREEK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTWOOD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24228-0768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-926-4979
Provider Business Practice Location Address Fax Number:
276-926-4426
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
JOHNNY
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
276-926-4979

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 370009593 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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