1114310224 NPI number — K-VAT FOOD STORES, INC

Table of content: (NPI 1114310224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114310224 NPI number — K-VAT FOOD STORES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
K-VAT FOOD STORES, 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:
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:
1114310224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1158
Provider Second Line Business Mailing Address:
ATTN: CONNIE REED
Provider Business Mailing Address City Name:
ABINGDON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24212-1158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-623-5100
Provider Business Mailing Address Fax Number:
276-623-5440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 WHITEWATER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCOEE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-216-0050
Provider Business Practice Location Address Fax Number:
423-299-9599
Provider Enumeration Date:
03/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
276-623-5100

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 00005532 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2150719 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: Q036789 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com