1093105140 NPI number — AGAP CONSUMER DIRECTED SERVICES, LLC

Table of content: (NPI 1093105140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093105140 NPI number — AGAP CONSUMER DIRECTED SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAP CONSUMER DIRECTED SERVICES, 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:
GOOD OLD DAYS - AT HOME CARE
Provider Other Organization Name Type Code:
3
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:
1093105140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/24/2018
NPI Reactivation Date:
04/25/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 951
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MECHANICSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23111-0951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-723-1374
Provider Business Mailing Address Fax Number:
804-591-0384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8090 MECHANICSVILLE TPKE STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MECHANICSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23111-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-723-1374
Provider Business Practice Location Address Fax Number:
804-591-0384
Provider Enumeration Date:
01/28/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
GWENDOLYN
Authorized Official Middle Name:
ANITA
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
804-723-1374

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: HCO-171518 , 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: 0164177690 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".