1164467577 NPI number — DR. WILLIAM BLAINE LIKINS III DC

Table of content: DR. WILLIAM BLAINE LIKINS III DC (NPI 1164467577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164467577 NPI number — DR. WILLIAM BLAINE LIKINS III DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIKINS
Provider First Name:
WILLIAM
Provider Middle Name:
BLAINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
DC
Provider Gender Code:
M

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:
1164467577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 TRINITY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24502-5264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-525-4588
Provider Business Mailing Address Fax Number:
434-525-4514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1084 THOMAS JEFFERSON RD
Provider Second Line Business Practice Location Address:
UNIT 12
Provider Business Practice Location Address City Name:
FOREST
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24551-2275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-525-4588
Provider Business Practice Location Address Fax Number:
434-525-4514
Provider Enumeration Date:
06/19/2006

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: 111N00000X , with the licence number:  0104555971 , 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: 461938 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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