1124244140 NPI number — COUNCIL OF SENIOR TYLER COUNTIANS, INC.

Table of content: (NPI 1124244140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124244140 NPI number — COUNCIL OF SENIOR TYLER COUNTIANS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNCIL OF SENIOR TYLER COUNTIANS, 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:
1124244140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 CHERRY STREET
Provider Second Line Business Mailing Address:
P.O. BOX 68
Provider Business Mailing Address City Name:
MIDDLEBOURNE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-758-4919
Provider Business Mailing Address Fax Number:
304-758-4680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
504 CHERRY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLEBOURNE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-758-4919
Provider Business Practice Location Address Fax Number:
304-758-4680
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
304-758-4919

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0030589000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0030589001 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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