1134408644 NPI number — MRS. IDA TRICE VACLAVIK NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134408644 NPI number — MRS. IDA TRICE VACLAVIK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VACLAVIK
Provider First Name:
IDA
Provider Middle Name:
TRICE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TRICE
Provider Other First Name:
IDA
Provider Other Middle Name:
SAWYER
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134408644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 WATKINS CENTRE PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MIDLOTHIAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23114-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-594-3130
Provider Business Mailing Address Fax Number:
804-423-6517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 WATKINS CENTRE PKWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MIDLOTHIAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23114-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-594-3130
Provider Business Practice Location Address Fax Number:
804-423-6517
Provider Enumeration Date:
08/15/2011

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: 363LF0000X , with the licence number:  RN1008705 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 0024172575 , 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: C09633 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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