1164508776 NPI number — STEVE'S VANS & ACCESSORIES UNLIMITED LLC

Table of content: (NPI 1164508776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164508776 NPI number — STEVE'S VANS & ACCESSORIES UNLIMITED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVE'S VANS & ACCESSORIES UNLIMITED 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:
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:
1164508776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 S 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45750-3349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-374-3154
Provider Business Mailing Address Fax Number:
740-374-9713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 S 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45750-3349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-374-3154
Provider Business Practice Location Address Fax Number:
740-374-9713
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HESSON
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
740-374-3154

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  84018902 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 311099975002 . This is a "MEDICAL MUTUAL OF OHIO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000242032 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2015250 . This is a "MEDICAL CASE MANAGEMENT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 6204048000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2015250 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31109997500 . This is a "BWC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 8400493 . This is a "MRDD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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